Kaiser Permanente researchers tested a patient activation intervention in primary care and found less depression, better overall health
Teaching people with chronic pain how to manage their medical care and use non-medication alternatives for pain may improve overall health and reduce depression, according to new research from Kaiser Permanente published in BMC Health Services Research.
The patient activation intervention was tested in a randomized trial with 376 Kaiser Permanente Northern California members who were on long-term opioid therapy for pain. Patient activation refers to having the skills and confidence to manage one’s own health and health care.
People taking the small-group classes did not take fewer opioids or have less pain than the patients in the control group. But they did have less depression, experienced better overall and physical health, accessed the online patient portal more, and used meditation and exercise for pain management more often.
“While pain severity and opioid use are important to track, we included a number of additional outcomes that are important to patients’ quality of life,” said lead author Monique Does, MPH, a senior research project manager with the Kaiser Permanente Division of Research (DOR). “These include things like function, mental health status, and navigating the Kaiser Permanente patient portal. It is encouraging that we saw improvement in some of these areas, and that they were sustained over a year’s time.”
The researchers worked with a large panel of patient, clinician, and operational stakeholders to develop the curriculum, implement the study, and choose the patient-centered secondary outcomes.
The intervention was originally designed by DOR Research Scientist Constance Weisner, DrPH, for use with people being treated for substance use disorder. The chronic pain research team, led by DOR Research Scientist Cynthia Campbell, PhD, adapted the intervention for patients with chronic pain.
“Primary care doctors are managing a lot of patients in pain, and we thought this intervention might be useful to activate patients around their own health and self-management,” said Campbell, senior author of the study. “Living with chronic pain often involves sleep disturbance, anxiety, depression, and difficulty with everyday tasks. Activated patients learn ways to manage those problems, and how to communicate more effectively and get assistance from their medical teams.”
The ACTIVATE trial was conducted in 2 primary care clinics between 2015 and 2018 and randomly assigned 189 participants to the intervention and 187 to usual care. The intervention consisted of 4 weekly 1.5 hour in-person sessions led by a clinical psychologist. Topics included talking to medical providers about pain, the mind-body approach to managing pain, stress management skills, using the online patient portal, and mindfulness and sleep improvement. All patients filled out a 13-question Patient Activation Measure questionnaire, and various aspects of their health status were tracked using questionnaires and the electronic health record.
After a year, the groups were assessed and the study found there was no difference in patient activation scores. But the intervention patients had better outcomes than the usual care group in several areas: less moderate/severe depression; more use of the patient portal to check test results and access health and wellness resources; more use of non-medication pain management strategies like meditation and exercise; and higher self-assessment of overall and physical health.
Does said the researchers were not sure why the activation measure did not show improvement after the intervention. “What came through strongly, though, was improvement in experiential things the patients practiced during the sessions, such as meditation or logging onto the patient portal,” she said.
It was also encouraging that a relatively short-term set of sessions could prompt long-term improvement in some areas, Campbell said. “Our hope was really to get something more bite-sized and manageable” than a traditional 8- or 10-week class, she said. “These findings show that smaller, less-intensive interventions further upstream in primary care can be really beneficial.”
The study was funded by the Patient-Centered Outcomes Research Institute.
Additional co-authors were Sara R. Adams, MPH, Andrea H. Kline-Simon, MPH, Nancy Charvat-Aguilar, MPH, Constance Weisner, DrPH, and Kelly Young-Wolff, PhD, of the Division of Research; Catherine Marino, PsyD, of the Kaiser Permanente physical medicine and rehabilitation department; Andrea L. Rubinstein, MD, and Murtaza Ghadiali, MD, of The Permanente Medical Group; and Penney Cowan of the American Chronic Pain Association.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.