Effectiveness of Telementoring in Improving Provider Knowledge, Attitudes, and Perceived Competence in Managing Chronic Pain: A Mixed Methods Study

ABSTRACT

Introduction

Telementoring is an evidence-based approach to meet the educational needs of primary care providers (PCPs) and to improve the quality of chronic pain care. This mixed methods study evaluated the effectiveness of pain management telementoring in improving provider knowledge, attitudes, and perceived competence.

Materials and Methods

The study was conducted at Madigan Army Medical Center. Using a non-randomized quasi-experimental approach, 25 providers were assigned to intervention arm and control arm (14 intervention and 13 control). Providers in the intervention group attended telementoring sessions. Videoconference technology was used to deliver weekly 90-minute TelePain sessions to the PCPs in the intervention group. The first 25-30 minutes of each session consisted of a didactic presentation led by a panel of interdisciplinary pain management clinicians. During the remaining 60 minutes, all PCPs in the intervention group presented clinical histories and asked specific management questions regarding patients of their choosing. An interdisciplinary panel of pain management clinicians provided telementoring consultations. The panel included experts from pain medicine, primary care, psychology or psychiatry, chiropractic, clinical pharmacy, and nursing. Changes in provider knowledge, attitudes, and perceived competence were evaluated using the Knowledge and Attitudes Survey Regarding Pain, KnowPain-12, and the Perceived Competence Scale (n = 23; 12 intervention and 11 control). Qualitative interviews were conducted among a subset of providers (n = 12; 8 intervention and 4 control), and provider narratives were analyzed using content analysis.

Results

Increased provider knowledge (Z = 2.0, P = .046 [KnowPain-12]) and perceived competence (Z = 2.1, P = .033) were observed among intervention group providers. Provider narratives supported more implementation of non-pharmacological pain management strategies, use of strategies to engage patients in reducing reliance on opioids, and perception of TelePain as a helpful resource especially in the context of inadequate preparation in chronic pain management during professional training.

Conclusions

Telementoring may hold significant potential to support providers in their efforts to decrease use of prescription opioids. Overall, this study provides further support for the value of telementoring in improving comprehensive chronic pain management in military settings.

INTRODUCTION

Chronic pain is experienced by approximately 126 million adults in the USA and represents the second most common reason for outpatient primary care visits.^1,2 However, the primary care providers (PCPs) making pain management decisions often receive inadequate and fragmented chronic pain education during their professional training,^3–5 and many report frustration, unpreparedness, low confidence, and dissatisfaction in managing this patient population.^2,6,7 Primary care providers (PCPs) are experts in chronic disease management and are uniquely positioned as frontline professionals to deliver the biopsychosocial pain care promoted in the National Pain Strategy,⁶ but the burden of chronic pain management is not the responsibility of the PCPs alone. To prevent provider burnout and ensure the comprehensive quality of care these patients deserve, it is important to provide team-based care and the support of interdisciplinary pain care services.^2,8 However, access to pain specialists may be limited,⁹ and obtaining chronic pain education as a practicing PCP can be challenging due to time constraints and costs associated with travel to conferences and workshops.

Telementoring is one approach to meeting PCP’s educational needs and to improving the quality of chronic pain care.¹⁰ Since its inception in 2003, Project ECHO (Extension for Community Healthcare Outcomes) has employed an interprofessional team of pain specialists at the “hub” site to train PCPs at the “spoke” sites remotely using videoconferencing technology.¹¹ The U.S. Army adopted the ECHO model in 2012, which includes weekly 90-120 minute clinician-to-clinician group telementoring sessions using a combination of didactic and case-based teaching.¹² The military is successfully applying the ECHO model to enhance the knowledge and comfort level of PCPs who manage patients with pain and subsequently improving the health and safety of active duty military retirees and dependents.¹¹

TelePain uses the same educational approach as the ECHO model to focus on non-opioid pain management, safe opioid prescribing, and expert consultation for pain and opioid misuse cases.¹³ An increasing number of studies support the value of telementoring in improving provider practices and patient outcomes in chronic pain management.^14–19 However, its value in military settings needs to be further explored. To further supplement the increasing knowledge base on effectiveness of pain telementoring in military settings and to obtain qualitative perspectives of military PCPs, this mixed methods study aimed to determine the effectiveness of pain telementoring in improving PCPs’ knowledge, attitudes, and perceived competence.

METHODS

Study Design and Setting

The PCPs were recruited at Madigan Army Medical Center (MAMC) in Tacoma, Washington. A convergent mixed methods design—a quasi-experimental non-randomized approach for intervention delivery followed by a qualitative descriptive approach—was used to examine the effectiveness of the telementoring intervention. These data are from a larger study designed to detect differences in patient outcomes. The PCP data are secondary to the study and considered an exploratory aim.

Sample

A total of 25 providers participated in the study. Due to predesignated pain champions (PCPs with relatively recent and extensive specialized training in managing pain, promoting and teaching good pain management practice among their peers, and providing pain management consultation to peers) and clinics with policies in place to promote telementoring participation, the researchers were logistically limited in their ability to randomly assign study providers to the intervention or control arm of the study. Hence, a non-randomized group assignment was used.

The intervention group (n = 14) comprised (1) eight primary care “Pain Champions” (six physicians, one nurse practitioner, and one physician assistant) designated by their family medicine and internal medicine clinics; (2) three providers (all nurse practitioners) assigned to the hospital Warrior Transition Battalion clinic, a special clinic established to care for active duty service members with complex medical conditions requiring limitations of military duties; and (3) one physician recruited from internal medicine clinical staff who was not a pain champion. Control group PCPs (n = 13), matched based on clinic characteristics, were non–pain champions, recruited from family and internal medicine clinics. Two PCPs (both physicians) participated in both groups, first as a control provider and then after selection as a new pain champion as an intervention provider. The purposive sample for qualitative interviews included 12 PCPs (eight from the intervention group and four from the control group). New PCPs were interviewed until data saturation was achieved, that is, until the quality, completeness, and amount of the information were sufficient and no new themes were elicited in the interviews.

Procedure and Intervention

All providers consented to study participation. All study procedures were approved by the Institutional Review Boards of the University of Washington and MAMC. Providers in the intervention arm participated in telementoring sessions. Videoconference technology was used to deliver weekly 90-minute TelePain sessions to the PCPs in the intervention group. The first 25-30 minutes of each session consisted of a didactic presentation. Topics were identified using the Joint Pain Education Program of the Defense and Veterans Center for Integrative Pain Management.²⁰ During the remaining 60 minutes, all PCPs in the intervention group presented clinical histories and asked specific management questions regarding patients of their choosing. Typically, the PCP presented patients on their own panel, but at times they presented patients for whom their colleagues had management questions. An interdisciplinary panel of University of Washington and MAMC pain management clinicians provided telementoring consultations. The panel included experts from pain medicine, primary care, psychology or psychiatry, chiropractic, clinical pharmacy, and nursing. To facilitate case discussions, PCPs submitted standardized de-identified patient histories in advance of the presentation. Ten of the intervention group providers (71%) participated in more than 25 telementoring sessions (range 26-74 during the 2-year study period), but four (29%) participated in 0-6 sessions; none of the four participated in qualitative interviews.

Data Collection

Measures

Pre- vs. post-intervention providers’ knowledge and attitude on pain management were assessed using the Knowledge and Attitudes Survey Regarding Pain (KASRP) and the KnowPain-12 survey. The KASRP, a 40-item questionnaire, has been extensively used as a pre- and post-test evaluation measure for educational programs.²¹ It contains 22 true or false questions and 18 multiple-choice items, and the scores range from 0 to 40. Higher scores indicate greater knowledge and more positive attitudes. The tool has established content and construct validity, and previous studies have demonstrated its internal consistency (alpha r > 0.70) and test–retest reliability (r > 0.80).²¹

The KnowPain-12 survey assesses knowledge regarding chronic pain management.²² KnowPain-12 has 12 items and uses a 6-category Likert-type scale. The PCP responses to the statements range from “strongly agree” to “strongly disagree.” A previous study examining the psychometric properties of KnowPain-12 reported a Cronbach’s α of 0.67 (indicating moderate internal consistency) and classification accuracy (area under curve) of 0.75 (indicating moderate ability to accurately distinguish between groups).²²

The PCP’s competence was assessed by the Perceived Competence Scale, which is based on the Self-Determination Theory.²³ The scale consists of a 4-item questionnaire that measures PCPs’ feelings of competence in managing chronic pain. The PCPs rate the questions related to confidence and ability to provide pain management, on a 7-point Likert scale ranging from “not at all true” to “very true.” The mean of the four items is the scale score, with higher scores denoting greater perceived competence. Previous studies have demonstrated significant internal consistency (Cronbach’s α value between 0.80 and 0.87), reliability, and validity.^23,24

Semi-structured interviews

The interviews were conducted by H.M. either in person in a private setting or over the phone. All interviews were audio-recorded and lasted between 30 and 60 minutes. A semi-structured interview guide was used, which contained open-ended questions focused on pain management, assessments and treatment plans, and patient–provider interactions.

Data Analysis

Quantitative analysis

With the exception of two providers who participated in both treatment arms, all providers who participated in either arm and provided outcome data were included in the analysis (n = 23). Descriptive statistics were used to describe demographic and military information. Treatment arms were compared using mixed effects regression models including categorical fixed effects for treatment arm, time (pre and post), and their interaction and random intercepts for providers. A full information maximum likelihood approach was employed to deal with missing data. Instead of imputing the values of missing data, the value of the population parameter was estimated by determining the value that maximizes the likelihood function based on the sample data that were present. Thus, all available data were utilized while estimating parameters. Missing data ranged from 9% to 13% depending on the outcome.

Qualitative analysis

Provider interviews were transcribed verbatim and verified by the interviewer (H.M.) for accuracy. Narratives were analyzed using a general inductive approach to content analysis^25,26 in ATLAS.ti 9.0.²⁷ The Framework Method was used to organize the codes and emergent categories.²⁸ Two researchers (A.M. and A.Z.D.) independently read five transcripts and coded significant meaning units. The various codes were compared based on differences and similarities and collated into categories. The initial codes and categories were discussed by both researchers (A.M. and A.Z.D.). In an iterative process, categories were continually redefined, revised, and collapsed. Four researchers with expertise in qualitative analysis independently reviewed the narratives and verified the final categories.

Mixed methods analysis

The mixed methods analysis aimed to enable meaningful expansion of survey results and understand the contextual factors.²⁹ Integration focused on the concordance between qualitative and quantitative results and utilized the technique of triangulation of datasets. Data were collected and analyzed separately and then combined at the point of interpretation, checking for agreement or disagreement between findings.

Trustworthiness

Several strategies were used to improve the trustworthiness of qualitative findings.^25,30 Peer debriefing with the research team at various stages of data abstraction established credibility. Verbatim extracts from multiple PCPs enhanced transferability and confirmability. The iterative coding process was accompanied with analytical memos. The transcripts were read multiple times before abstracting categories, to ensure that all relevant data have been included. The data were continually compared with the research findings and interpretations, to ensure that the categories accurately reflected the meanings evident in the data set as a whole.

RESULTS

The demographic characteristics of the providers (n = 23; 12 intervention and 11 control) are presented in Table I. Approximately 70% of the PCPs (16/23) were physicians (MD or DO), and the rest were nurse practitioners (NPs). Their average years of practice ranged from about 17 to 20 years. The qualitative sample included eight MDs or DOs and four NPs.

TABLE I.

Demographic Characteristics of Providers

	Quantitative survey (n = 23)		Qualitative interview (n = 12)
	Control providers	Intervention providers	Control providers	Intervention providers
	(n = 11)	(n = 12)	(n = 4)	(n = 8)
Discipline, % (n)
Nurse practitioner	27.3 (3)	33.3 (4)	50.0 (2)	25.0 (2)
Physician	72.7 (8)	66.7 (8)	50.0 (2)	75.0 (6)
Gender,% (n)
Female	27.3 (3)	50.0 (6)	50.0 (2)	50.0 (4)
Male	72.7 (8)	50.0 (6)	50.0 (2)	50.0 (4)
Race
White	90.9 (10)	66.7 (8)	100.0(4)	62.5(5)
Other	9.1 (1)	33.3 (4)	0.0(0)	37.5(3)
Years of practice, mean (SD)	20.6 (11.7)	17.5 (11.0)	16.8 (4.5)	17.2 (7.2)

Integration of the quantitative and qualitative findings revealed that there were improved knowledge and attitudes on chronic pain management as well as improved perceived competence in assessing and managing chronic pain patients. Wherever applicable, the survey results refer back to the whole sample, while the quotations are from the intervention group PCPs who participated in the qualitative interviews.

Improved Knowledge Regarding Chronic Pain Management

As shown in Table II, the control group had a slight decrease in knowledge (Time coefficient = 0-0.002) and the intervention group showed a substantial increase (Time + Group × Time = −0.002 + 0.4 = 0.398). The difference in change in knowledge from pre- to post-intervention for the intervention group compared to the controls was statistically significant (KnowPain-12 Z = 2.0, P = .046). The KASRP score showed a similar pattern but differences were not statistically significant (Z = 1.4, P = .168), indicating no significant improvement in attitudes. These survey findings were expanded meaningfully through the provider narratives. The PCPs shared that the “training they received in school was very minimal” (PCP 10, NP) or that they “did not have direct experience with” (chronic pain management) “during residency” (PCP 11, MD or DO). Among the providers who were interviewed, only 58% had some level of formal pain training such as courses on suboxone prescribing, ECHO training, or didactic pain management training programs. In this context, providers reported that the intervention made up for their lack of expertise and academic preparation in chronic pain management. They described that the telementoring sessions were “excellent resources” (PCP 1, MD or DO) and “of great educational value” (PCP 7, MD or DO).

TABLE II.

Pre- Vs. Post-Intervention Change in Knowledge, Attitudes, and Perceived Competence by Study Group (N = 23)

Measures	Coefficient	SE	Z	P > Z	95% CI
(a) KnowPain-12
Group	−0.1	0.2	−0.4	.682	−0.4-0.3
Time	−0.002	0.1	−0.01	.989	−0.3-0.3
Group × Time	0.4	0.2	2.0	.046	0.006-0.8
(b) Knowledge and Attitudes Survey Regarding Pain (KASRP)
Group	−3.1	1.8	−1.7	.086	−6.7-0.4
Time	0.5	1.3	0.4	.701	−2.0-2.9
Group × Time	2.6	1.9	1.4	.168	−1.1-6.3
(c) Perceived Competence Scale
Group	−7.1	0.4	−1.9	.055	−1.4-0.02
Time	0.2	0.3	0.75	.452	−0.4-0.8
Group × Time	0.9	0.4	2.1	.033	0.1-1.8

The TelePain conferences are helpful. The didactics are good.…all in all, I’ve been really pleased with the TelePain (PCP 4, MD or DO).

Until Telementoring, I pretty much spurned chronic pain as something I sought to attend additional CMEs on. It seemed too painful and hopeless… I have to say I’ve found the TelePain really, really, helpful (PCP 7, MD or DO).

Most of the pain management training I’ve received has been, actually, through this (TelePain) program (PCP 10, NP).

I’ve had a pleasure learning, attending the sessions. It has widened my education, my experience, the way I approach patients with pain, it has changed (PCP 11, MD or DO).

Although there was no statistically significant increase in attitudes as measured by the KASRP, providers in the intervention arm also reported using strategies such as “listening with positive feedback” (PCP 12, MD or DO), “spending time getting to know the patient” (PCP 4, MD or DO), “listening to patients’ stories and letting them express” (PCPs 6 and 10 NP; PCP 11, MD or DO), “not interrupting patients or pre-diagnosing” (PCP 10, NP), and “expectation management” (PCP 7, MD or DO). They also reported attitudes of “being empathetic” (PCP 1, MD or DO; PCP 4, MD or DO), “not seeking out aberrant behaviors” and “trusting patients’ reports of pain” (PCPs 4, 5, 11, and 12, MD or DO; PCPs 6 and 10, NPs). Intervention arm providers described “realistic goal-setting” (PCP 10, NP) and “expectation management” (PCP 7, MD or DO) while managing patients with chronic pain. Realistic goal setting involved discussions with the patient regarding focusing on goals such as resumption of activities, improved function, and quality of life. It also involved helping patients on high-dose opioids to reduce reliance on pain medications.

Improved Perceived Provider Competence in Managing Chronic Pain

The survey participants in the intervention arm showed significantly greater increases in perceived competence (Z = 2.1, P = .033). This improved confidence and ability to manage chronic pain, observed in the survey, was expanded through the provider narratives on how they assessed pain, collaborated with interdisciplinary pain management support sources, communicated with patients, and involved patients in decision-making. Providers in the intervention arm narrated their strategies of “asking the right questions” to interpret a patient’s chronic pain story, in addition to screening for pain, opioid use, anxiety and depression, and post-traumatic stress disorder. These questions were “tailored to the patient rather than a specific protocol” (PCP 5, MD) and focused on pain history, triggers of pain, and areas impacted by pain—sleep patterns, function, mood, vocation, family, and social life. They also reported that tools like the PASTOR (Pain Assessment Screening Tool and Outcomes Registry, a web-based battery of assessments developed as a result of the Army Pain Management Task Force) were helpful and expressed their desire for expanded access to it.

Furthermore, providers described that TelePain faculty were “a wealth of pain specialists” (PCP 1, MD or DO) and that PCPs “collaborated with them” (specialists) “for assistance or some guidance” (PCP 11, MD or DO). The PCPs expressed that telementoring led to a whole array of services being available to work with, in the primary care lane, thus improving their confidence in using non-pharmacological modalities. To manage chronic pain, participants described that they did not “rely solely on pain medications” but rather were focused on “minimizing reliance on opioids” (PCPs 4, 5, 7, 11, and 12, MD or DO; PCP 10, NP) and “rechanneling patients’ efforts away from being a medication oriented treatment to a biopsychosocial model” (PCP 12, MD or DO). Providers also described their experiences of having patient discussions on benefits of alternative modalities and using a balanced treatment plan which incorporated both active and passive modalities. They reported referring patients for non-pharmacological therapies such as physical therapy, sleep, nutrition, and massage and were interested in offering even more resources such as behavior modification, group therapy, acupuncture, and chiropractic. Providers reported that when they prescribed passive modalities like pain medications, acupuncture, or massage, they encouraged patients to commit to active modalities such as exercises or cognitive behavioral therapy. One provider described this approach as “transactional” (PCP 7, MD or DO), which involved an agreement of a partnership and shared responsibility in managing chronic pain.

After telementoring, PCPs reported that they “don’t worry about seeing a patient” (with chronic pain) “on their schedule” (PCP 11, MD or DO) and are able to get patients to be “open minded to a number of different resources to treat pain, as opposed to just pharmaceuticals” (PCP 1, MD or DO). Additionally, provider confidence in using resources other than pharmacological modalities was enhanced when they observed visible improvement in patients who were discussed during telementoring and were offered complementary and integrative health therapies. These patient benefits included reduced reliance on opioids, improved pain and associated symptoms, and resumption of activities of daily living.

You know, the biggest difference in the patients I’ve presented and treated through telementoring, is that their pain is gone, they’re off doing things in life that are good for them….they’re out doing and enjoying what’s unique for them. That’s where you want them to be (PCP 6, NP).

DISCUSSION

This mixed methods study evaluated the impact of pain management telementoring on PCP outcomes through a non-randomized controlled trial and provider interviews. The authors found that participation in telementoring improved provider knowledge and perceived competence. These findings are congruent with previous studies that reported increases in pain knowledge and competence or confidence following telementoring participation.¹⁰ A pre- vs. post-intervention analysis of 24 PCPs at a Veterans Affairs medical center revealed significant increases in pain knowledge and confidence as well as qualitative improvements in provider’s self-efficacy, knowledge, and relationships with specialists following participation in pain telementoring.¹⁵ Our qualitative findings further revealed the context of increased provider knowledge and competence. The intervention was perceived as making up for their lack of expertise in chronic pain management due to poor academic preparation. With only 3% of medical schools in the USA including pain-specific education in their curriculum and inadequate pain management training in undergraduate and advanced practice nursing curricula, chronic pain remains an orphan disease in professional education.^31–33 In this context, telementoring has a huge potential in improving the knowledge and competence of currently practicing PCPs.

Providers in the intervention group reported that they implemented more non-pharmacological pain management strategies that they used in everyday clinical practice. These strategies included using multimodal treatments which included active interventions such as physical therapy and cognitive behavioral strategies balanced with passive strategies such as massage or acupuncture. Similar findings have been reported previously in other studies conducted in military settings.^17,19 Participation in pain telementoring was associated with greater reductions in the number of opioid prescriptions per patient and average morphine equivalent dosage prescribed per patient¹⁷ and an increase in referrals to physical medicine, initiation of antidepressant and anticonvulsant medications, and improved pain medication practices.¹⁹ Although actual provider practices of assessing and managing chronic pain were not observed in this study, study findings are in line with the need for incorporating cognitive behavioral, mindfulness-based, and exercise-based interventions in the management of chronic pain in primary care.⁸ In the context of the existing opioid epidemic,³⁴ telementoring may hold significant potential to enhance PCP knowledge and competence to decrease the use of prescription opioid drugs.

The telementoring intervention providers also reported using strategies such as use of goal setting and expectation management and focusing on improving function and quality of life. They took efforts to redirect patients’ focus on realistic pain management goals such as resumption of activities and function. This enhanced patient engagement and thus conveyed an understanding of shared responsibility in managing chronic pain. These findings support the current profound shift in focus from eliminating or fixing pain toward improving the experience of individuals with chronic pain and enhancing functioning and quality of life.²

Providers in this study referred to telementoring faculty as a wealth of specialists and collaborated with them to manage chronic pain. Patients with chronic pain are complex and often have other comorbidities. Furthermore, providers have described feeling “alone” or “isolated” while caring for patients with chronic pain.¹⁴ This is especially important in primary care because PCPs care for a complex group of patients with chronic pain that rivals the complexity of those seen in specialized tertiary care pain management facilities.³⁵ In this challenging clinical situation, pain management telementoring is a promising intervention. Involvement in TelePain and having a virtual community with whom PCPs can share concerns and questions could reduce the PCP burden of managing chronic pain. The PCPs participating in similar telementoring have reported that involvement in TelePain reduced feelings of isolation and found it helpful to have someone to bounce ideas off.¹⁴ Furthermore, similar collaborative education in other clinical topics could be of great value for PCPs.

More recently, the commitment to pain management telementoring was reaffirmed in the 2018 Defense Health Agency Procedural Instruction 6025.04 on Pain Management and Opioid Safety in the Military Health System³⁶ and the Office of the Secretary of Defense Report to the Congress on the implementation of a comprehensive policy on pain management by the Military Health Care System.³⁷

Limitations

Limitations of this study include the lack of random sampling strategy and a small sample size. Findings are limited to one Army medical center and may not be generalizable to other settings. In addition, findings from provider interviews represent the small sample of military PCPs consisting of physicians and NPs only and may not be representative of a wider provider population. Future research should include other military sites to improve the sample size and generalizability to other military settings.

CONCLUSION

This study demonstrated a significant effect of pain telementoring on provider knowledge and perceived competence in management of chronic pain patients. In combating the opioid epidemic, telementoring may hold significant potential to provide support to PCPs to decrease the use of prescription opioid drugs. Telementoring could be particularly promising for providing education and consultation to PCPs in geographically remote or resource-limited settings. Further research should focus on dissemination and implementation trials.

SUPPLEMENTARY MATERIAL

Supplementary Material is available at Military Medicine online.

FUNDING

This work was supported by grants from the National Institute of Nursing Research of the National Institutes of Health R01NR012350 and K24NR015340 (A.Z.D.).

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to report.