Approximately one in six Australians report low back pain at any one time, with 50% of the population reporting low back pain in the past month. This accounts for approximately $4.8 billion in Australia every year with direct health care costs. Low back pain is also the leading cause of disability world-wide with 540 million people globally affected by activity limiting low back pain. Key messages from the recent Lancet Series on Low Back Pain reveal that health care for low back pain is largely fragmented and poorly coordinated with most patients receiving low-value care that is not evidence-supported (e.g. opioids, routine imaging). A clear example of this practice is the high rate of presentations to emergency care for LBP. A recent analysis of consecutive ED visit charts in the USA identified over half of all presentations are for pain, of which 13% are for low back pain.
A recent study conducted in Australia showed that low back pain can comprise up to 2% of all ED presentations, with each ED presentation for LBP in Australia requiring an average of 4.5 hours of ED time, and costing tax-payers up to AUD2,5006. Our analysis of NSW Admitted Patient Data Collection also showed over 307,000 ED presentations for LBP in NSW between 2003 and 2012 (average of 30,000/year or AUD7.7million/year). There is also evidence that around one in five of these patients will represent6. ED representation rates for low back pain range from 12%6 to 19%7 creating a cycle of low-value care. Whereas most currently advocated models of care of LBP focus on ED admitted patient care, we lack evidence-based, integrated post-discharge monitoring. This fragmented and uncoordinated care leads to the high representation rates we have observed in EDs across Australia.
A common problem is that patients discharged from hospital may not adhere to adequate management. A promising way to facilitate behaviour change and improve adherence is health coaching. In recent years there has been a growing body of evidence showing that health coaching is a beneficial intervention to address weight loss and physical activity in a variety of chronic diseases such as diabetes, myocardial infarction, cancer and chronic Pulmonary disease. Evidence of its use in the low back pain population, however, appears to still be in its infancy and current randomised clinical trials vary substantially in terms of the way and how frequently it is delivered. For this reason, no firm consensus has been reached on the value, acceptability and safety of this intervention for patients with low back pain.
In response to increasing hospital readmissions and burden of low back pain, we developed a health coaching intervention based on promoting healthy lifestyle behaviour (e.g. weight reduction, sleep quality, physical activity promotion, pain coping strategies) for patients with low back pain. The goal was to improve management by coordinating patient access to appropriate conservative care and by empowering the patient to better control their disease and reduce disability, pain and rates of unnecessary surgery.
In partnership with the Physiotherapy Department of Royal North Shore Hospital, we provided a telephone support service to monitor patients with low back pain who are discharged from ED.
Pilot study aims were to test:
- The feasibility of the trial procedures, including: screening and recruitment procedures, baseline assessment and data collection procedures
- Delivery process of the intervention components.
- The feasibility of health coaching intervention/goal setting delivery
The evaluation of the pilot process is important to fine tune the delivery of the service at the primary care level, before evaluating its effectiveness in a future randomised control trial.
Of the participants in this pilot study, 100% considered the support phone service was an acceptable and 80% a useful service with 90% of the participants willing to receive the service again if required in the future. The phone contact frequency and length were also considered to be acceptable in 80% and 100% of participants respectively. There was a positive response from participants with regard to both managing their symptoms better and functional improvements reported in 90%.
The pilot study identified that although the educational information was easy to understand, the content could be improved further in order to increase how helpful participants perceive it to be. The most common area of support reported to be of use was advise on exercise and physiotherapist provision of reassurance, pain education and medications.
The analysis of the Emergency physiotherapists feedback, who identified potential participants found that time taken to and difficulty in identifying relevant patients were the main barriers along with the small number of patients that presented during their usual working hours. They also identified the lack time allocated to provide the service due to lack of funding and failure of patients to answer the phone to scheduled calls as further barriers to the service. Failure of participants to answer scheduled calls occurred twice during the pilot study.
Analysis of the time taken from patient identification to patient enrolment into the study also found that the pilot study processes required streamlining to reduce this time from an average of 7.3 days to 2 days.
Ways to reduce this time frame were identified as:
- Requirement of a site coordinator present in the Emergency department in order to identify, appropriately screen patients and to provide study information prior to their discharge.
- Automatic generation of the baseline (enrolment) survey immediately after the completion of the online consent form to reduce the time taken for the patient to be sent and then access this survey prior to their enrolment.
- Provision of the first assessment phone call over weekends as this was identified as the most common delay between study enrolment occurring on a Friday and the initial phone support call unable to be provided until the following Monday.
The phone support service was widely accepted and positively received by the participants involved. Although the clinical outcomes for the pilot study were not analysed as this was not the aim, previous studies providing health coaching style phone support for patients with low back pain have showed that health outcomes are no worse. The economic evaluation of a health coaching phone service has also shown that it reduces the costs of healthcare for those receiving the service in comparison to those who continued with usual care.
The current evolving pandemic situation involving COVID-19 highlights the utility of providing phone or videoconference consultation to patients that require self-isolation, quarantine or are vulnerable. The accessibility and ease of use of such technology would ensure timely support is still provided to those in need whilst protecting the health of the community at large.
The process evaluation of this pilot study has been used to inform the study designs for 2 further new projects:
- ConnectED: Telecare health coaching for patients with low back pain discharged from Emergency Departments
- Deprescribing opioids in patients with low back pain and hip or hip osteoarthritis