 |
|
Can a Back Pain E-mail Discussion Group Improve Health Status and Lower Health Care Costs?
A Randomized Study
Kate R. Lorig, DrPH;
Diana D. Laurent, MPH;
Richard A. Deyo, MD;
Margaret E. Marnell, PhD;
Marian A. Minor, PhD;
Philip L. Ritter, PhD
Arch Intern Med. 2002;162:792-796.
ABSTRACT
| |
Background Given the high health care utilization, limited evidence for the effectiveness
of back pain interventions, and the proliferation of e-mail health discussion
groups, this study seeks to determine if the Internet can be used to improve
health status and health care utilization for people with chronic back pain.
Methods Randomized controlled trial. Participants included 580 people from 49
states with chronic back pain having at least 1 outpatient visit in the past
year, no "red-flag" symptoms, and access to e-mail. Major exclusion criteria
included continuous back pain for more than 90 days causing major activity
intolerance and/or receiving disability payments.
Intervention Closed, moderated, e-mail discussion group. Participants also received
a book and videotape about back pain. Controls received a subscription to
a non–health-related magazine of their choice.
Main Outcome Measures Pain, disability, role function, health distress, and health care utilization.
Results At 1-year treatment, subjects compared with controls demonstrated improvements
in pain (P = .045), disability (P = .02), role function (P = .007), and health
distress (P = .001). Physician visits for the past
6 months declined by 1.5 visits for the treatment group and by 0.65 visits
for the control group (P = .07). Mean hospital days
declined nearly 0.20 days for the treated group vs and increased 0.04 days
for the control group (P = .24).
Conclusions An e-mail discussion group can positively affect health status and possibly
health care utilization. It may have a place in the treatment of chronic recurrent
back pain.
INTRODUCTION
IN RECENT YEARS, the Internet has become a source for health information.
In many cases, this information has become a source of support for people
with similar health conditions. Today, there are hundreds if not thousands
of health-related Internet support groups. However, few of these groups have
been evaluated. Thus, this study seeks to answer the question: Can a behavioral
intervention delivered via the Internet affect the quality of life and health
care utilization among people with chronic recurrent back pain?
Chronic recurrent back pain is one of the most highly prevalent medical
conditions. After respiratory tract infections, it is the most common symptomatic
reason people seek health care.1 Its direct
economic impact has been estimated at $24 billion, while the indirect impact
may be as high as $50 billion.1 Although there
have been many educational and behavioral attempts to affect the pain, disability,
and health care utilization associated with chronic back pain, findings from
previous back pain education programs have been equivocal.
Cohen et al2 reviewed 13 primary studies
of group education for people with low back pain. They concluded in the 6
well-designed studies that there was "insufficient evidence to recommend group
education for people with low back pain."
Di Fabio3 conducted a meta-analysis of
back schools with or without a comprehensive rehabilitation program. These
programs increased strength and endurance (effect size, 0.40) and compliance
(effect size, 0.27). They had little effect on utilization or lost workdays.
A recent Cochrane review by van Tulder et al4
suggests that exercise is not useful in the acute phase of back pain but that
combined exercise programs may help prevent recurrence or reduce chronic back
pain.
Turner5 has examined cognitive behavioral
interventions for low back pain. She reviewed 12 studies that used 1 or more
cognitive or behavioral approach, some combined with exercise. In most of
the studies, cognitive behavioral approaches seemed to be superior to usual
care. Four of the studies had sufficient data to be included in a meta-analysis.5 Effect sizes ranged from -0.36 to -1.57
for pain and from -0.16 to -1.16 for functional disability. No
specific cognitive or behavioral intervention seemed to be superior. The Agency
for Health Care Policy and Research guidelines dealing with low back pain
found only moderate evidence supporting patient education as an intervention
for this condition.6 None of these studies
used the Internet as a mode of program delivery.
According to a 1999 Harris Poll,7 68%
of Internet users seek health-related information, and among the most frequently
accessed sites are those for musculoskeletal conditions. The Internet can
be used to seek information and/or to gain support through chat rooms conducted
in real time, or bulletin boards or e-mail discussion groups which do not
take place in real time. The randomized study described herein involves an
intervention, consisting of a moderated e-mail discussion group, a videotape,
and a book about back pain, with the objectives of improving quality of life
(disability, pain, role function, and psychological distress), while lowering
health care utilization.
SUBJECTS AND METHODS
Subjects were recruited from workplaces, through public service announcements,
and by donated Web page banners on Yahoo!, an Internet search engine. To enroll
in the study, subjects were directed to a Web site that described the study.
The entire enrollment process occurred through the study Web site. This Web
site was accessed approximately 46 000 times during the enrollment period.
Of these, 2056 completed the eligibility form and of 889 eligible, 580 completed
the informed consent and baseline study questionnaire. Eligibility criteria
included having at least 1 outpatient visit for back pain in the past year,
no "red-flag" symptoms (back pain accompanied by unintended weight loss, pain
not improved with rest, back pain secondary to significant trauma, acute onset
of urinary retention or overflow incontinence, loss of anal sphincter tone
or fecal incontinence, saddle anesthesia, or global or progressive motor weakness
in the lower limbs), access to a computer and an e-mail account, and living
in the United States. Subjects were excluded if they had back pain that had
continued for more than 90 consecutive days and continued to cause major activity
intolerance, were planning back surgery, were currently receiving disability
insurance payments for back pain, were unable to understand and write English,
were pregnant, had back pain due to systemic disease, had a severe comorbid
condition that limited functional ability, or had a terminal illness. Of the
1167 who failed the eligibility criteria, 14% had not been to a physician
regarding their back in the last year, 14% had bladder or bowel control problems,
12% had numbness in their crotch area, and 13% were receiving disability or
workers' compensation payments for their back problems.
DESIGN
Names and e-mail addresses of potential subjects were collected during
a 4-month period. Six weeks before going online all those who expressed interest
were asked to complete the eligibility questionnaire. If they qualified, potential
subjects then completed the informed consent process and the study questionnaire.
After completing this questionnaire, they were randomized to treatment or
control status. All treatment subjects entered the intervention at the same
time, within 6 weeks of completing baseline data. Control subjects continued
with usual care and received a subscription to their choice of popular non–health-related
magazines. All subjects in both groups simultaneously completed study questionnaires
6 and 12 months after baseline.
INTERVENTION
The intervention consisted of 3 parts: a closed e-mail discussion group
in which all group members received all e-mails sent by group members, moderators,
and content experts; a copy of The Back Pain Helpbook8; and a videotape that modeled how to continue an active
life with back pain.
In the discussion group, all members received e-mail sent by any member
or moderator. There was no real-time discussion. The discussion group had
2 moderators and 3 content experts, a physician with expertise in back pain,
a physical therapist, and a psychologist. The moderators served as group leaders.
For example, if there had been no e-mail for several days, a moderator might
ask a question to stimulate interaction. Participants were not allowed to
be judgmental or negative to other participants, nor were they allowed to
discuss individual health care professionals. There were no other limits on
discussion topics. One of the moderators maintained the technical aspects
of the discussion groups, such as removing members at their request, changing
e-mail addresses, notifying users of computer viruses, and troubleshooting
computer problems.
The content experts were available to answer general questions and comment
on the discussion. They were not allowed to give individual medical advice.
They estimated their online time to be 2 or less hours per week. There was
no attempt by either the moderators or content experts to direct or end discussion,
although sometimes when the discussion was inactive, a content expert might
make a comment or ask a question to stimulate discussion. In general, the
Agency for Health Care Policy and Research back pain guidelines were used
in giving advice.6
The Back Pain Helpbook8
was written for a previous study and emphasizes the principle that "hurt does
not equal harm." This was accomplished by discussing the Agency for Health
Care Policy and Research guidelines and making recommendations for self care.
The book was included as part of the intervention so that participants could
have a specific reference concerning exercise and other treatments.
Finally, treatment subjects received a videotape produced by Northern
California Kaiser Permanente Medical called Easing Back:
Taking Control of Your Back Problem. The videotape had vignettes of
several people with back pain who told their stories and discussed how they
were able to live and work with back pain. The videotape did not teach specific
exercises but rather emphasized posture and walking. The purpose of adding
the videotape to the intervention was to provide the subjects with models
of appropriate back care behaviors.
STUDY VARIABLES
All data were collected by self-administered questionnaires. All subjects
completed the baseline questionnaire online. Ten percent requested to complete
either the 6- or 12-month questionnaire by mail, and 2% completed both questionnaires
by mail. Primary outcomes for this study were changes in quality of life (pain,
disability, role function, and health distress) and changes in health care
utilization (back-related visits to physicians, physical therapists and chiropractors,
and back-related days of hospitalization). Secondary outcomes included endurance
exercise, self-care orientation, and self-efficacy.
All instruments had been previously validated. Pain was measured with
a visual numeric scale, a variation of the more traditional visual analog
scale.9 Disability was measured by the revised
Roland-Morris Scale, which was specifically developed to study disability
caused by back pain.10-12
Role function was measured by the Illness Intrusiveness Scale, which measures
how much one's illness interferes with 5 areas of life: physical well being,
work and finances, married and family life, recreational and social activities,
and other aspects of life.13 Health Distress
(the amount of time one has felt worried, fearful, or frustrated about health
problems) is a short scale developed for the Medical Outcomes Study.14 All utilization measures were self-reported. In a
recent study, Ritter et al15 have found that
self-reported utilization compares favorably with utilization recorded by
medical chart audit and electronic medical records. Furthermore, they established
that there is no gold standard for utilization data as there are problems
with all 3 methods. However, the correlation between self-report and medical
chart audits and electronic medical records is generally in the range of 0.8
or better. Self-efficacy was measured by combining previous instruments. The
new 6-item measure has an  = .85. Self-care orientation was measured
using a scale developed by Saunders et al.16
STATISTICAL ANALYSES
First, to test the randomization, we compared the baseline variables
for treatment vs control subjects using simple t
tests. Second, all hypotheses were tested using analysis of covariance to
estimate 1-year scores, controlling for demographic variables and baseline
status. One-year change scores were also computed. Third, intent-to-treat
analyses were performed by first substituting the last known data (baseline
or 6 month) for missing 12-month data and then repeating the analyses of covariance.
Finally, we used regression analyses to examine if 6-month changes in self-efficacy
and self-care orientation were associated with 1-year outcomes.
RESULTS
At 6 months, 202 treatment subjects (68%) and 252 control subjects (89%)
completed data. At 12 months, 190 treatment subjects (64%) and 231 control
subjects (81%) completed the study. During the first days of the intervention,
the number of e-mails per day exceeded 150. This caused 54 treatment subjects
to discontinue the intervention during the first month of the intervention.
These subjects were invited back into the intervention 2 times during the
first year. Of the 107 treatment subjects who requested to be removed from
the intervention during the first year, 43 returned to the intervention. Data
were requested from all subjects who had been randomized, irrespective of
their actual participation in the intervention. Demographics of subjects at
baseline are given in Table 1.
|
|
|
|
Table 1. Baseline Data for Treatment and Control Groups and Baseline
Data for Those Completing 1 Year of Treatment
|
|
|
At baseline, the only significant (P<.01)
difference between treatment and control subjects was that a greater percentage
of control subjects were married. Examining the baseline differences between
treatment and control subjects who completed 1 year, only age approached significance
(P = .05) with the treatment subjects being older.
The earlier difference in marital status disappeared, suggesting a greater
tendency for unmarried subjects to discontinue the study.
During the yearlong study, a total of 2399 e-mail messages were posted
to the group. A total of 204 (69%) of the treatment subjects sent 1 or more
e-mail messages to the group. Forty-one percent of subjects reported reading
most or all the e-mail messages, while an additional 37% of the subjects reported
reading only the e-mail messages of interest to them. The 211 subjects remaining
active members of the discussion group at the end of 1 year posted e-mail
messages a mean of 8.0 times (median, 2).
Sixty-eight percent of the subjects reported that they had watched the
entire videotape, 24% had not watched it, and 18% had watched part of the
videotape. Most participants reported that they had read part of the book
(mean, 56%). Only 33% had read the entire book, and 12% had not read any of
the book.
At 1 year, treatment subjects compared with controls demonstrated significant
improvements in all 4 of the primary health status variables (pain, disability,
role function, and health distress) (P<.05, Table 2). For health care utilization (visits
to physicians, chiropractors, and physical therapists, as well as hospital
days), the treatment group demonstrated greater declines than the control
group. For physician visits, this approached significance (P = .07). Physician visits for the past 6 months declined by 1.54 visits
for the treatment group and 0.65 visits for the control group. Mean hospital
days declined nearly 0.25 days for the treated group and increased 0.04 days
for the control group (P = .24).
|
|
|
|
Table 2. Baseline Mean (SD) Health Status and Health Care Utilization
Values and 1-Year Mean (SD) Changes*
|
|
|
Two other variables that might have influenced health status and health
care utilization were also examined, self-care orientation and self-efficacy.
Self-care orientation and self-efficacy were significantly enhanced in the
treated group (both 9%) compared with the control group (4% and -2%)
(P = .01 and P = .003, respectively).
It may be that study dropouts, if included, would have significantly
influenced the study outcomes. To investigate this possibility, we performed
intent-to-treat analyses. The results were nearly the same as with the analyses
that excluded dropouts (Table 2).
Using the intent-to-treat analysis, the reduction in hospital days approached
significance (P = .08).
In addition, baseline and 6-month changes in self-efficacy were associated
with 12-month health status. Specifically 6-month changes in self-efficacy
were significantly (P<.001) associated with 1-year
changes in disability, health distress, pain interference, and role function
(Pearson r = -0.20, -0.33, -0.18,
and 0.26, respectively). Using regression models, we calculated adjusted health
status variables at 1 year. Independent variables used in the model were the
health status variables at baseline, self-efficacy at baseline, 6-month change
in self-efficacy, and demographic variables (age, sex, education, married,
and non-Hispanic white). Baseline self-efficacy and 6-month change in self-efficacy
were associated with 1-year disability, health distress, pain interference,
and role function at the  0.001 level. In these models, baseline demographic
variables did not significantly predict 1-year outcomes, except that older
age was associated with higher levels of disability. When we added baseline
self-care orientation and 6-month change in self-care orientation to the regression
models, both were significantly associated with physician utilization at 1
year (P = .02, P = .005,
respectively). Thus 6-month changes in self-efficacy seem to be associated
with 1-year improvements in health status, while 6-month changes in self-care
orientation seem to be associated with 1-year reductions in physician utilization.
COMMENT
This study suggests that a simple low-cost use of the Internet may improve
health status and lower health care utilization for persons with recurrent
back pain. The question is whether these changes are clinically significant.
Fischer et al17 found that arthritis patients
rated a 30% improvement in disability as meaningful and satisfying. In this
study, patients achieved a 34% reduction in disability (effect size, 0.3).
Another important question involves potential savings. When we examined
utilization, the treatment group reduced their total outpatient utilization
from 9.47 visits in the 6 months before baseline to 4.32 visits in months
6 to 12 of the study, for a total reduction of 5.15 visits. The control group
reduced their visits from 8.55 to 5.74 for a total of 2.81 visits. Thus, the
treatment group had 46% fewer visits than the control group during the last
6 months of the study. This same pattern, although not statistically significant,
was observed in hospital days with the treatment group reducing hospital days
by 0.20 compared with less than 0.05 days for the control group. These reductions,
if replicated in other groups, could represent substantial savings because
of the high utilization patterns of people with recurrent back pain. The cost
of the intervention was approximately $15 per person for the book and videotape
and approximately 11 hours per week of professional time (2 hours per week
for each of 3 content experts and 5 hours a week for the moderators). Using
a professional salary of $100 000/year, the total cost of the intervention
per participant was approximately $100. This would be increased if the purchase
of computers and software were included.
With improved health status and health care utilization, one must ask
why these changes occurred. It is not possible to identify the individual
contributions of the various parts of the intervention. However, we do know
that most past educational interventions for back pain have been ineffective.
At the same time, Turner5 has suggested that
psychobehavioral interventions may be more effective in the treatment of this
condition. From our data, it seems that baseline self-efficacy as well as
changes in self-efficacy may be important contributors to the positive health
status outcomes.
There are several caveats. It may be that those participating in the
intervention were a select group. During a 3- to 4-month recruiting period,
46 000 people had at least an initial interest as indicated by hits on
the study Web site. In addition, the utilization rates and disability scores
of study subjects do not differ greatly from those reported in the general
population. In fact, the subjects in this study may be more representative
than in past studies. They came from 49 states and had a wide age range. On
the other hand, we had few minority subjects and, of course, those without
Internet access were excluded.
In addition, this study did not include recurrent back pain patients
receiving disability compensation. This was intentional to avoid the problems
sometimes encountered with the competing demands of improvement in condition
with the desire to maintain disability benefits. We are currently beginning
a replication study for people who have applied for workers' compensation
because of low back pain.
In conclusion, while there are many caveats and much more to be learned
about the use of an Internet discussion group for persons with chronic health
conditions, this is one of the first randomized studies to investigate this
new delivery mechanism, to our knowledge. The results suggest that a combination
of information and support largely offered through an Internet discussion
group improves health status and health care utilization for up to 1 year.
In the future, we will learn much more about the potential and limitations
of this new media for delivering health care interventions.
AUTHOR INFORMATION
Accepted for publication July 31, 2001.
The study was supported by grant RO1 AR44939-02 from the National Institutes
of Health, Bethesda, Md.
Corresponding author and reprints: Kate R. Lorig, DrPH, Stanford
Patient Education Research Center, 1000 Welch Rd, Suite 204, Palo Alto, CA
94304 (e-mail: lorig{at}stanford.edu).
From Stanford University School of Medicine (Drs Lorig and Ritter and
Ms Laurent) and Department of Psychiatry, Stanford University Medical Center
(Dr Marnell), Stanford, Calif; University of Washington, School of Medicine,
Seattle (Dr Deyo); and Department of Physical Therapy, University of Missouri,
Columbia (Dr Minor).
REFERENCES
| |
1. Wipf JE, Deyo RA. Low back pain. Med Clin North Am. 1995;79:231-246.
ISI
| PUBMED
2. Cohen JE, Goel V, Frank J, Bombardier C, Peloso P, Guillemin F. Group education interventions for people with low back pain: an overview
of the literature. Spine. 1994;19:1214-1222.
ISI
| PUBMED
3. Di Fabio R. Efficacy of comprehensive rehabilitation programs and back school for
patients with low back pain: a meta-analysis. Phys Ther. 1995;75:865-878.
FREE FULL TEXT
4. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the
framework of the Cochrane collaboration back review group. Spine. 2000;25:2784-2796.
FULL TEXT
|
ISI
| PUBMED
5. Turner JA. Educational and behavioral interventions for back pain in primary care. Spine. 1996;21:2851-2857.
FULL TEXT
|
ISI
| PUBMED
6. Bigos S, Bowyer O, Braen G, et al. Clinical Practice Guideline No. 14: Acute Low Back
Problems in Adults. Rockville, Md: US Dept of Health and Human Services, Agency for Health
Care Policy and Research, Public Health Service; 1994. AHCPR publication 95-0642.
7. Ferguson T. The Ferguson Report: The Newsletter of Online Health. April 1999:No. 2.
8. Moore J, Lorig K, Von Korff M, González V, Laurent D. The Back Pain Helpbook. Cambridge, Mass: Perseus Publishing; 1999.
9. González V, Stewart A, Ritter P, Lorig K. Translation and validation of arthritis outcome measures into Spanish. Arthritis Rheum. 1995;38:1429-1446.
PUBMED
10. Roland M, Morris R. A study of the natural history of back pain, part 1: development of
a reliable and sensitive measure of disability in low-back pain. Spine. 1983;8:141-144.
ISI
| PUBMED
11. Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J. Defining the minimum level of detectable change for the Roland-Morris
Questionnaire. Phys Ther. 1996;76:359-368.
FREE FULL TEXT
12. Beurskens A, de Vet H, Koke A, Van der Heijden G, Knipschild P. Measuring the functional status of patients with low back pain. Spine. 1995;20:1017-1028.
ISI
| PUBMED
13. Devins G, Mandin H, Hons R, et al. Illness intrusiveness and quality of life in end-stage renal disease:
comparison and stability across treatment modalities. Health Psychol. 1990;9:117-142.
FULL TEXT
|
ISI
| PUBMED
14. Stewart AL, Hays RD, Ware JE. Health perceptions, energy/fatigue, and health distress measures. In: Stewart AL, Ware JE, eds. Measuring Functioning
and Well Being: The Medical Outcomes Study Approach. Durham, NC: Duke
University Press; 1992.
15. Ritter P, Stewart A, Kaymaz H, Sobel D, Bloch D, Lorig K. Self-reports of health care utilization compared to provider records. J Clin Epidemiol. 2001;54:136-141.
FULL TEXT
|
ISI
| PUBMED
16. Saunders KW, Von Korff M, Pruitt SD, Moore JE. Prediction of physician visits and prescription medicine use for back
pain. Pain. 1999;83:369-377.
FULL TEXT
|
ISI
| PUBMED
17. Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D, Holman H. Capturing the patient's view of change as a clinical outcome measure. JAMA. 1999;282:1157-1162.
FREE FULL TEXT
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Overtreating Chronic Back Pain: Time to Back Off?
Deyo et al.
J Am Board Fam Med 2009;22:62-68.
ABSTRACT
| FULL TEXT
The Role of Online Support Communities: Benefits of Expanded Social Networks to Patients With Psoriasis
Idriss et al.
Arch Dermatol 2009;145:46-51.
ABSTRACT
| FULL TEXT
Clinical trials studying pharmacotherapy and psychological treatments alone and together
Haythornthwaite
Neurology 2005;65:S20-S31.
ABSTRACT
| FULL TEXT
Nonpharmacologic and Complementary Approaches to Cancer Pain Management
Menefee and Monti
JAOA: Journal of the American Osteopathic Association 2005;105:S15-S20.
ABSTRACT
| FULL TEXT
Automated E-mail Messaging as a Tool for Improving Quit Rates in an Internet Smoking Cessation Intervention
Lenert et al.
J. Am. Med. Inform. Assoc. 2004;11:235-240.
ABSTRACT
| FULL TEXT
Evaluation of ehealth systems and services
Gustafson and Wyatt
BMJ 2004;328:1150-1150.
FULL TEXT
The Long-term Effects of a Self-management Program for Inner-city Primary Care Patients With Acute Low Back Pain
Damush et al.
Arch Intern Med 2003;163:2632-2638.
ABSTRACT
| FULL TEXT
Innovations in Access to Care: A Patient-Centered Approach
Berry et al.
ANN INTERN MED 2003;139:568-574.
ABSTRACT
| FULL TEXT
Use of the Internet and E-mail for Health Care Information: Results From a National Survey
Baker et al.
JAMA 2003;289:2400-2406.
ABSTRACT
| FULL TEXT
Group Education in Diabetes: Effectiveness and Implementation
Mensing and Norris
Diabetes Spectr. 2003;16:96-103.
ABSTRACT
| FULL TEXT
The doctor, the patient and the world-wide web: how the internet is changing healthcare
Powell et al.
JRSM 2003;96:74-76.
FULL TEXT
From the Library
Br. J. Ophthalmol. 2002;86:1195-1195.
FULL TEXT
E-mail Support Group Helps Patients with Back Pain
JWatch General 2002;2002:5-5.
FULL TEXT
|
