Clinical and cost-effectiveness of communication skills e-learning for primary care practitioners on patients’ musculoskeletal pain and enablement: the Talking in Primary care (TIP) cluster-randomised controlled trial

Abstract

Objectives: to determine the effectiveness and cost-effectiveness of a brief communication skills e-learning package on empathy and optimism for practitioners consulting with adult primary care patients presenting with musculoskeletal (MSK) pain.

Design: a cluster randomised controlled trial from 31/10/22 to 28/6/24 using computer-generated block randomisation allocated general practices to intervention or usual care control (1:1) stratified by practice size and deprivation. Patients, trial statisticians, investigators, and researchers involved in collecting outcome data were blinded to allocation. Practitioners were not told which patients were participating in the trial.

Setting: general practices in England and Wales (all NHS general practices eligible).

Participants: adults ≥18y consulting a participating practitioner face-to-face, by telephone, or videoconference were recruited into two groups prior to consultation: those consulting about new, recurrent, or ongoing MSK pain and scoring ≥ 4 on an 11-point scale at baseline; and those consulting for any other reason (All-comers). Participating primary care practitioners came from a range of disciplines (e.g., GPs, nurse practitioners, first-contact physiotherapists) and routinely saw patients with MSK pain.

Interventions: intervention arm practitioners received EMPathicO, an evidence-based theoretically-grounded, brief digital e-learning package using behaviour change techniques to enhance communication of clinical empathy and realistic optimism. Control arm practitioners did not receive EMPathicO and consulted patients as usual, access to EMPathicO was provided upon trial completion.

Main outcomes: the MSK pain group patient-level dual primary outcomes were pain intensity and patient enablement. The All-comer group patient-level primary outcome was patient enablement. All outcomes were analysed over 6 months using a repeated-measures approach. Cost effectiveness was assessed from UK NHS and societal perspectives including personal expenses and productivity over 6 months.

Results: 53 general practices were randomised (25 intervention, 28 control) from which 233 practitioners (115 intervention, 118 control) and 1682 patients were recruited (806 in the MSK pain group (439 intervention, 367 control) and 876 in the All-comers group (490 intervention, 386 control)). Intention to treat analysis found no statistically significant differences between intervention and usual care on primary outcomes. Among the MSK pain group, pain intensity adjusted mean difference was 0.06 (97.5% CI -0.19 to 0.31) and patient enablement adjusted mean difference was 0.17 (97.5% CI -0.05 to 0.40). Among the All-comers group, patient enablement adjusted mean difference was -0.12 (95% CI -0.32 to 0.07). We found no evidence of harm associated with the intervention. From a UK NHS perspective, the probability of cost-effectiveness at a willingness to pay threshold of £20,000 per quality-adjusted life year was 97% for the MSK pain group and 64% for the All-comers group. Compared to control, intervention practitioners had significantly higher self-efficacy for communicating empathy and optimism at 8 weeks (empathy adjusted mean difference was 0.78 (95% CI 0.45 to 1.10), optimism adjusted mean difference was 0.98 (95% CI 0.59 to 1.37)) and 34 weeks post-intervention (these mean differences were 0.63 (95% CI 0.32 to 0.93) and 0.75 (95% CI 0.39 to 1.10), respectively).

Conclusions: brief e-learning for primary care practitioners significantly increased practitioner self-efficacy for a sustained period, is probably cost-effective, and is safe for patients but did not improve pain intensity, patient enablement or other health outcomes. EMPathicO could be rapidly and widely disseminated to support practitioners delivering primary care consultations.

Registration: ISRCTN18010240 registered 15 September 2022. Funding: NIHR School for Primary Care Research grant 563.

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Identifiers

ORCID for Felicity L. Bishop: orcid.org/0000-0002-8737-6662

ORCID for Taeko Becque: orcid.org/0000-0002-0362-3794

ORCID for Nadia Cross: orcid.org/0000-0002-4148-7180

ORCID for Rachel Dewar-Haggart: orcid.org/0000-0002-3757-1152

ORCID for Emma Teasdale: orcid.org/0000-0001-9147-193X

ORCID for Beth Stuart: orcid.org/0000-0001-5432-7437

ORCID for Leanne Morrison: orcid.org/0000-0002-9961-551X

ORCID for Sebastien Pollet: orcid.org/0000-0001-9924-9225

ORCID for Jane Vennik: orcid.org/0000-0003-4602-9805

ORCID for Helen Atherton: orcid.org/0000-0002-7072-1925

ORCID for Geraldine M. Leydon: orcid.org/0000-0001-5986-3300

ORCID for Nazrul Islam: orcid.org/0000-0003-3982-4325

ORCID for Paul H. Lee: orcid.org/0000-0002-5729-6450

ORCID for Paul Little: orcid.org/0000-0003-3664-1873

ORCID for Hazel A. Everitt: orcid.org/0000-0001-7362-8403

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