Automated Mobile Phone Messaging Utilizing a Cognitive Behavioral Intervention: A Pilot Investigation

Abstract

Background:

In the setting of outpatient orthopaedic surgery, this pilot study utilized automated mobile messaging to assess (1) the feasibility of and interaction rates with a software delivered cognitive behavior therapy (CBT) intervention for postoperative opioid utilization, (2) the reliability of patient reported opioid utilization through our platform, (3) daily patient reported pain and opioid utilization within the first two postoperative weeks, and (4) the effect of software delivered CBT intervention on patient reported opioid utilization.

Methods:

Musculoskeletal tumor patients scheduled for outpatient surgery were randomized into two study groups. Control patients received standard postoperative communication limited to a two-week postoperative follow-up visit. The intervention group received automated daily text-messages regarding pain, opioid utilization, and a daily CBT intervention. Interventional group patients also completed a patient satisfaction questionnaire at their two-week follow-up. Completion rates of all software delivered questions were determined in the interventional group. Median values of opioid utilization and interquartile range (IQR) were determined to compare utilization between groups. Spearman correlation coefficients were used to determine reliability of patient reported opioid utilization in the interventional group.

Results:

Fourteen patients completed the pilot study (seven controls, seven intervention). Patients in the intervention arm completed 90% of pain and opioid questions. Intervention group patients utilized less of their daily prescribed opioid medication (20%, IQR:10%-27%) compared to controls (50%, IQR:4%-68%). Correlation between in-office pill counts and patient reported opioid medication utilization via our software messaging system was high (r=0.90, p=0.037).

Conclusion:

Automated mobile phone messaging in outpatient tumor surgery yielded high interaction rates. Patient reported opioid utilization obtained through our platform demonstrated a high correlation with in-office pill counts. CBT delivered via automated mobile phone messaging demonstrated decreased opioid utilization in this pilot investigation.

Level of evidence: II

Introduction

Opioid prescriptions rose sharply in the 1990s in a response to calls for better patient pain control.^1-3 This historical increased use of opioids led to the epidemic we are experiencing today, with over 60% of drug overdose deaths involving the use of opioids in recent years.⁴ Opioids continue to be a consistently utilized analgesic for relief of post-operative pain, and opioid misuse poses a great challenge for orthopaedic surgeons as they provide the third most opioid prescriptions among physicians.^{1, 5}

Opioid medications are particularly important in patients with musculoskeletal tumors as these patients not only suffer from immediate post-operative pain, but also chronic pain that is multifactorial in nature.⁵ Patients with cancer, especially those with bone involvement, suffer from pain due to the sensitization and stimulation of nerve fibers that innervate bone.⁶ Chronic opioid use can lead to hyperalgesia and increased narcotic demand in the postoperative setting, warranting increased diligence to minimize the risks of opioid overdose.⁷

Understanding of pain and pain medication utilization has been difficult following orthopaedic surgical interventions, in part due to a lack of standardized daily interactions or communication between patients and their surgical team to assess and advise on postoperative pain and narcotic use. Previous work has investigated automated mobile phone text messaging as a means to communicate with patients on a daily basis, with favorable results.^8-10 This technology can deliver predefined questions, reminders, and instructions to patients directly to their mobile device, and is an effective way to collect patient data at a minimal cost.^{9, 11-13}

Cognitive behavior therapy (CBT) is a common psychological intervention that has been shown to help patients cope with chronic pain.¹⁴ Prior work suggests that CBT improves post-surgical pain and that mobile phone delivery of CBT interventions may improve pain catastrophizing.^15-17

In the setting of patients with musculoskeletal tumors undergoing outpatient orthopaedic surgery, this pilot study aimed to use automated mobile phone messaging to assess (1) the feasibility of and interaction rates with a software delivered CBT intervention for postoperative opioid utilization, (2) the reliability of patient reported opioid medication utilization through our designed software platform, (3) daily patient reported pain and opioid medication utilization in this patient population in the first two postoperative weeks, and (4) the effect of a software delivered cognitive behavior therapy (CBT) intervention on patient reported opioid medication utilization.

Methods

This pilot investigation was approved by our institutional review board and deemed HIPAA compliant. Patients presenting to musculoskeletal tumor clinic were approached for possible inclusion in the study if they were undergoing an outpatient musculoskeletal tumor procedure. Patients provided informed consent. Patients choosing to participate were then randomized to one of two study arms utilizing a random number generator. The control arm received standard of care postoperative communication consisting of discharge from the outpatient surgery center and subsequent two-week postoperative follow-up appointment. No software messaging was sent to the control group. The intervention arm received daily text messages inquiring about pain and opioid use for that day, as well as a CBT intervention consisting of daily messages giving general postoperative guidance and encouragement. The CBT intervention messages also encouraged decreasing opioid medication utilization over the first two postoperative weeks (Table 1). The intervention group also attended the standard two-week postoperative follow-up visit. Patients in both groups were instructed to bring their opioid pill bottles with them to clinic at their two-week postoperative visit. Additionally, all patients in both groups were instructed according to our standard postoperative pain control protocol, which includes advising patients to elevate their operative extremity, apply ice as needed, and call our clinic with any concerning signs including intractable pain, excessive swelling or consistent fevers.

Table 1.

Automated Mobile Message Content and Chronology

Postoperative Day	Morning Cognitive Behavior Intervention Message
1	Its normally to be in pain after surgery. You are just beginning a healing process! Consider elevating your operative extremity to help with any pain and swelling you might be having.
2	Surgery sometimes causes temporary symptoms including numbness, tingling, cold, burning, or pain in and around the area of your procedure. These symptoms should decrease day by day!
3	Remember to pace your activities right after surgery. We want you to be active but remember to not overdo it right after surgery! Slowly progress your activity so that you are not having any unnecessary pain.
4	Remember post-surgical symptoms are temporary, think positive thoughts today and remember that your body is recovering and healing!
5	Know that you are supported after surgery. You are not alone! Get together with family or friends today if you have time. We are always here for you if you need us!
6	You are now 1 week out from surgery. Your healing process continues! Consider reducing your pain medication use if you have not already done this.
8	Your body continues to heal itself. Bone, muscle, and skin all make significant healing gains over the first postoperative week. Keep up the good work!
10	You are now 1.5 weeks out from your surgical procedure, congratulations you’ve made it through the toughest part! Take time today to reflect on how far you’ve come since surgery.
12	You are now almost 2 weeks into the recovery process! We look forward to seeing you in clinic soon and discussing the progress you have made!
	Evening Pain Rating Question
0-14	Please rate your pain on a scale of 0-10, with 0 being no pain and 10 being the most pain you have ever felt.
	Evening Opioid Pill Utilization Question
0-14	How many tablets of prescription pain medication have you taken in the past 24 hours?

The messaging protocol completion rate was calculated for the intervention group. The average pain and opioid use reported by the patients in the intervention group was evaluated by day. The percentage of the prescribed, maximum allotted daily opioid medication patients reported taking was assessed via median values and interquartile range (IQR) across all participants in the intervention group utilizing patient reported pill counts through our software and compared to median value manual pill counts obtained from the control group at two-week follow-up. We elected to utilize median values and IQR to describe our groups given the pilot nature of this study and the small sample size. Pill counts in the intervention group reported via mobile phone messaging were compared to their manual pill count at two-week follow-up and evaluated utilizing Spearman correlation coefficients. Correlation was interpreted based on previously reported definitions of excellent (>0.70), excellent-good (0.61-0.70), good (0.31-0.60), and poor (0.2-0.3).¹⁸ Statistical analyses were performed using Microsoft Excel (Microsoft Corp., Redmond, WA). Alpha level for significance was set a priori at 0.05.

Results

A total of 17 patients were enrolled with nine randomized to the control group and eight patients randomized to the intervention group. The control group consisted of all mass excisions, the intervention group consisted of six mass excisions and one curettage and bone grafting (Table 2). Average age was 45±13 years and nine of the 17 patients were female. Two of the patients in the control group did not return with their pill bottles and thus could not be further evaluated regarding opioid utilization. One patient from the messaging group decided not to participate in the study after signing up. After exclusion of these patients, there were 14 total patients with seven patients in both the control and interventional groups.

Table 2.

Procedures Undergone by Participating Patients

Intervention Group
	Count	Procedures
	4	Knee mass excision
	1	Arm mass excision
	1	Osteochondroma excision
	1	Curettage and bone grafting
Control Group
	1	Chest mass excision
	1	Leg sarcoma excision
	2	Knee mass excision
	1	Elbow lipoma excision
	2	Thigh mass excision
	1	Foot mass excision
	1	Arm soft tissue excision

There was a 90% completion rate of all pain and opioid questions through two weeks among patients in the intervention arm. The two-week total of daily patient reported pill counts in the intervention group demonstrated good correlation with the pill counts from the returned bottles at the two-week postoperative visit (r=0.90, p=0.037) and is presented in Table 3. In the intervention arm, 86% of patients felt the automated software messages made them feel “somewhat” or “much more” connected to their care team, 71% preferred postoperative communication via messaging versus phone (voice) or email, and 57% of patients would ask for the messaging system again if they were to undergo another procedure.

Table 3.

Interventional Group Patients Clinic Visit vs. Reported Pill Count

Participant	Clinic Visit Pill Count	SMS Reported Pill Count
1	**	2
2	24	26
3	**	4
4	0	16
5	3	4
6	59	59
7	17	17

SMS, Short Messaging Service; **Patient did not return prescription opioid medication bottle at 2-week follow-up.

Daily median pain and opioid utilization (Figure 1) decreased in the intervention group over the course of the first two postoperative weeks. On post-operative day (POD) one the median reported pain in the interventional group was five (range 0-8) and 3.5 tablets of pain medication (range 0-9). On POD 10 the median reported pain was zero (range 0-5) with zero tablets of opioid medication utilized (range 0-4). The intervention group utilized 20% (IQR:10%-28%) of their prescribed narcotic over the first two postoperative weeks versus 50% (IQR:4%-68%) utilization in the control group. In the intervention group, five of seven patients were no longer utilizing opioids on POD 11 and six of seven were no longer utilizing opioids on POD 13.

Figure 1.

Daily median pain and opioid demand in interventional group patient.

Discussion

Mobile phone and software communication platforms are beneficial in the delivery of patient reported outcomes and treatment of many conditions including alcohol use disorder, HIV antiretroviral treatment, and diabetes.^{10, 11, 19, 20} Previous work found mobile phone communication provided better data collection in comparison to traditional methods in patients answering post-surgical pain questions.²¹ Additionally, the patients reported the post-surgical mobile pain surveys were more convenient than traditional communication methods.²¹ Understanding of software interaction rates in the orthopaedic tumor population is important given evidence that increased communication, including via text messaging, in cancer patients helps this patient population cope better with their treatment and is ultimately associated with better treatment outcomes.^{13, 22} Our group has previously utilized automated mobile phone messaging to interact with different patient populations finding interaction rates that approach 90%.^{23, 24} The current investigation showed that patients undergoing outpatient procedures for musculoskeletal tumors demonstrated a high interaction rate (90%) with an automated mobile phone messaging platform. We also found there was a high correlation between patient reported opioid medication utilization via our software platform and manual pill counts in clinic in this pilot investigation (r=0.90). In the post study follow-up questionnaire, patients predominantly stated they preferred text messaging communication versus other modern forms of telephone (voice) communication or email in the postoperative period. Additionally, four of seven patients stated they would want to utilize the mobile phone messaging platform again if they were to undergo another procedure. We found that patients were generally accepting of our postoperative communication platform and interacted with the software at a high rate. Our results also suggested a good correlation between opioid medication data collected via automated mobile phone messaging and manual pill counts in clinic, though, further formal investigations are required to validate this finding. Given our findings, subsequent investigations can utilize our software communication methods when attempting to obtain postoperative pain and opioid data and also when trialing possible CBT interventions across different patient populations.

Controlling patient’s pain, specifically patients with cancer, contributes to their ability to cope with their treatment and achieve a better quality of life.^{5, 25} Current understanding of the daily and short term utilization of opioid medication after outpatient orthopaedic tumor surgery is limited. This data, in addition to the natural history of patient reported pain after outpatient musculoskeletal procedures, would be beneficial during patient counseling and benchmarking for normative values. Patients in the intervention group of this study showed a gradual reduction in patient reported pain scores and opioid utilization over the two-week study period (Figure 1). Though this investigation is limited in scope due the nature of the pilot investigation, our results suggested a down trending course of pain and opioid medication utilization over the first two postoperative weeks with nearly all patients reporting they were no longer utilizing opioid medications by the end of the second postoperative week.

Acute and chronic pain is affected by psychological factors including pain catastrophizing, which ultimately results in interference with the patient’s activities of daily living and a lower quality of life. Mobile app and text messaging communication with patients using the principles of CBT is noted to be helpful and efficacious in the treatment of several psychological conditions and cognitive problems, including pain catastrophizing.^{16, 17} This pilot investigation demonstrated lower patient reported opioid utilization in the experimental group receiving automated software communication that was designed on the principles of CBT, compared to a control group that did not receive software CBT messaging. Although our pilot investigation was not powered to comment on the statistical significance of our results, we report that delivery of automated mobile phone messaging protocols implementing CBT may be a way to decrease opioid utilization in the acute postoperative period. Further work with a larger patient population is indicated to determine the true efficacy of mobile phone and software delivered CBT in the orthopaedic tumor patient population and other orthopaedic patient populations.

This study was not without limitations. First, the study was a single center and single surgeon feasibility study which may not necessarily make our results reproducible across other healthcare settings. Second, our study was designed to test the feasibility and patient acceptance of daily automated mobile phone messages and a CBT intervention and thus had a small sample size and was not sufficiently powered to report findings of possible statistical significance. We also identify the patient population we studied was undergoing relatively low morbidity, outpatient surgery. This potentially skews our results and warrants further investigation utilizing similar methods in patients who are undergoing more extensive procedures, those with chronic pain, and patient populations who have been previously identified to be at risk for postoperative opioid utilization.^26-29 Finally, the two-week follow up period was short and longer studies would be needed to observe effects long-term on patient outcomes.

Conclusions

High mobile phone messaging interaction rates with our software driven communication platform and CBT intervention suggest this is a feasible method and communication intervention to test in other patient populations. Interaction rates are high in orthopaedic tumor patients using automated mobile phone messaging to assess postoperative daily pain score and opioid use. Obtaining postoperative opioid medication utilization data via automated mobile phone messaging suggested a good correlation with in-office pill counts at two weeks. CBT delivered via our software may reduce opioid use in orthopaedic tumor patients, though further work with appropriately powered studies are needed to properly assess this observation.