A smartphone-based health care chatbot to promote self-management of chronic pain (SELMA) : pilot randomized controlled trial

Background: Ongoing pain is one of the most common diseases and has major physical, psychological, social, and economic impacts. A mobile health intervention utilizing a fully automated text-based health care chatbot (TBHC) may offer an innovative way not only to deliver coping strategies and psychoeducation for pain management but also to build a working alliance between a participant and the TBHC. Objective: The objectives of this study are twofold: (1) to describe the design and implementation to promote the chatbot painSELfMAnagement (SELMA), a 2-month smartphone-based cognitive behavior therapy (CBT) TBHC intervention for pain self-management in patients with ongoing or cyclic pain, and (2) to present findings from a pilot randomized controlled trial, in which effectiveness, influence of intention to change behavior, pain duration, working alliance, acceptance, and adherence were evaluated. Methods: Participants were recruited online and in collaboration with pain experts, and were randomized to interact with SELMA for 8 weeks either every day or every other day concerning CBT-based pain management (n=59), or weekly concerning content not related to pain management (n=43). Pain-related impairment (primary outcome), general well-being, pain intensity, and the bond scale of working alliance were measured at baseline and postintervention. Intention to change behavior and pain duration were measured at baseline only, and acceptance postintervention was assessed via self-reporting instruments. Adherence was assessed via usage data. Results: From May 2018 to August 2018, 311 adults downloaded the SELMA app, 102 of whom consented to participate and met the inclusion criteria. The average age of the women (88/102, 86.4%) and men (14/102, 13.6%) participating was 43.7 (SD 12.7) years. Baseline group comparison did not differ with respect to any demographic or clinical variable. The intervention group reported no significant change in pain-related impairment (P=.68) compared to the control group postintervention. The intention to change behavior was positively related to pain-related impairment (P=.01) and pain intensity (P=.01). Working alliance with the TBHC SELMA was comparable to that obtained in guided internet therapies with human coaches. Participants enjoyed using the app, perceiving it as useful and easy to use. Participants of the intervention group replied with an average answer ratio of 0.71 (SD 0.20) to 200 (SD 58.45) conversations initiated by SELMA. Participants’ comments revealed an appreciation of the empathic and responsible interaction with the TBHC SELMA. A main criticism was that there was no option to enter free text for the patients’ own comments. Conclusions: SELMA is feasible, as revealed mainly by positive feedback and valuable suggestions for future revisions. For example, the participants’ intention to change behavior or a more homogenous sample (eg, with a specific type of chronic pain) should be considered in further tailoring of SELMA

Integrated health and care systems in England : can they help prevent disease?

Objectives: Over the past 12 months, there has been increasing policy rhetoric regarding the role of the NHS in preventing disease and improving population health. In particular, the NHS Long Term Plan sees integrated care systems (ICSs) and sustainability and transformation partnerships (STPs) as routes to improving disease prevention. Here, we place current NHS England integrated care plans in their historical context and review evidence on the relationship between integrated care and prevention. We ask how the NHS Long Term Plan may help prevent disease and explore the role of the 2019 ICS and STP plans in delivering this change. Methods: We reviewed the evidence underlying the relationship between integrated care and disease prevention, and analysed 2016 STP plans for content relating to disease prevention and population health. Results: The evidence of more integrated care leading to better disease prevention is weak. Although nearly all 2016 STP plans included a prevention or population health strategy, fewer than half specified how they will work with local government public health teams, and there was incomplete coverage across plans about how they would meet NHS England prevention priorities. Plans broadly focused on individual-level approaches to disease prevention, with few describing interventions addressing social determinants of health. Conclusions: For ICSs and STPs to meaningfully prevent disease and improve population health, they need to look beyond their 2016 plans and fill the gaps in the Long Term Plan on social determinants

Are antibiotics effective for treating acute bronchitis? Evidence update - Summary of a Cochrane Review

Antibiotics have modest effects for treating patients with acute bronchitis

What are the benefits and risks of restrictive versus routine episiotomy during vaginal birth? Evidence update - Summary of a Cochrane Review

Restrictive episiotomy policies, where health staff avoid the procedure, appear to have a number of benefits compared to policies where episiotomies are performed routinely

Rationalising health care provision under market incentives: experimental evidence from south Africa

Unnecessary medical treatments place a significant burden on health systems striving for universal health coverage (UHC). This thesis studies inappropriate treatment incentives in the private sector in South Africa, where plans to implement a national health insurance system (NHI) foresee the contracting of private physicians to deliver publicly-funded health care. Private providers are increasingly recognized as necessary partners for UHC success in many low-and-middle-income countries (LMIC). However, aligning the incentives of these actors with UHC and public health goals requires a better understanding of incentive effects in these settings. I conduct two field experiments with incognito standardized patients (SPs), to both evaluate appropriate care provision and experimentally vary the treatment incentives facing private physicians. First, I run a within-subject experiment with 89 private primary care physicians (GPs) in Johannesburg, to investigate the causal impact of improving patients’ financial protection (insurance cover) on physicians’ quality of care delivery. The results suggest that more insured patients receive a higher level of visible clinical effort, but a lower level of technical care quality – including a higher likelihood of inappropriate antibiotic treatment. Second, I use data from the same experiment to evaluate the impact of patient insurance on the quantity and costs of care. I find that more insured patients are more likely to receive unnecessary diagnostic tests and treatment procedures, and receive more and more expensive branded drugs, resulting in significantly higher care costs. The results on antibiotic treatment and drug treatment quantity and costs occurred despite the absence of any financial incentives attached to drug prescribing for GPs, which suggests the presence of alternative motives for physicians’ treatment decisions that might vary with patient insurance – including intrinsic or altruistic motives. Third, I explore the scope for leveraging such intrinsic motivations to improve physicians’ treatment choices. I conduct a randomized (between-subject) experiment with 80 GPs, to evaluate the impact of intrinsic, informational incentives from private performance audit and feedback (A&F) on physicians’ antibiotic treatment choices and care costs. The findings suggest that private A&F can significantly reduce the likelihood of inappropriate antibiotic treatment for common viral infections that present in primary care, without simultaneously reducing appropriate antibiotic use for bacterial infections or increasing other inappropriate drug treatments. However, improved performance on antibiotic use does not coincide with significantly lower treatment costs or any improvements in measured diagnostic effort or accuracy. There is indicative evidence that prescribing norms and perceived patient expectations may play an important role in mediating private physicians’ treatment choices in all three empirical chapters

Do psychological treatments reduce symptoms of post-traumatic stress disorder? Evidence update - Summary of a Cochrane Review

Trauma focused cognitive behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management, and group TFCBT reduce traumatic symptoms in post-traumatic stress disorder

Do beta-blockers prevent heart disease and strokes in people with high blood pressure? Evidence update - Summary of a Cochrane Review

In people with high blood pressure, there is no evidence that beta-blockers reduce the number of deaths. Beta-blockers reduce the risk of stroke but are less effective than calcium channel blockers (CCBs) or renin-angiotensin system (RAS) inhibitors

In areas where diarrhoeal disease is common, do interventions that aim to improve the quality of drinking water prevent diarrhoea? Evidence update - Summary of a Cochrane Review

Researchers have tested a range of interventions applied at the water source, and at the point of use. Those tested all helped reduce diarrhoea in all age groups

Does training for traditional birth attendants benefit pregnant women and their babies? Evidence update - Summary of a Cochrane Review

Traditional birth attendant training can improve outcomes of pregnancy when combined with improved health services