Andrea Furlan1,2,3, Jane Zhao1, Jennifer Voth4, Samah Hassan1,3, Ruth Dubin5, Jennifer Stinson6,7, Susan Jaglal7,8, Ralph Fabico1, Andrew Smith9, Paul Taenzer10, John Flannery1

1. Introduction

Chronic pain (CP) is a prevalent problem in the province of Ontario. Healthcare providers (HCPs) manage the majority of CP patients, yet receive minimal training 1. Project ECHO™ (Extension for Community Healthcare Outcomes) is a model that uses telehealth technology to bridge specialists in academic centres to HCPs in remote areas 2. ECHO Ontario Chronic Pain and Opioid Stewardship aims to disseminate knowledge and enhance capacity in HCPs across Ontario 3.

ECHO Ontario runs weekly 2-hour sessions that starts with a 20-min didactic on a CP topic followed by a de-identified patient case discussion presented by one of the HCP attendees. For every case presented, case presenters receive recommendations for potential management approaches 3.

1. Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada 2. Dept of Medicine, University of Toronto, Toronto 3. Institute of Medical Science, University of Toronto 4. ICES, Toronto 5. Dept of Family Medicine, Queen’s University, Kingston, Ontario 6. Hospital for Sick Children, Toronto 7. Institute of Health Policy, Management, and Evaluation, University of Toronto 8. Dept of Physical Therapy, University of Toronto 9. Centre for Addiction and Mental Health, Toronto 10. Depts of Medicine, Oncology, and Psychiatry, University of Calgary, Calgary, Alberta, Canada

ECHO ONTARIO: Impact on Health Care Providers

2. Objectives

• To evaluate the impact of ECHO on HCPs’ self-efficacy, knowledge, attitudes and behaviours related to chronic pain management and opioid prescribing.

• To evaluate HCPs’ satisfaction after attending ECHO.

• To evaluate if the type of professions, presenting a case at ECHO, or the number of ECHO sessions attended modified the results.

3. Methods

A pre-post online questionnaire was administered to HCPs who attended ECHO sessions.

• Demographics;

• Self-Efficacy: a 19-item validated questionnaire from UNM regarding CP management and opioid use 2;

• Attitudes and behaviours: 7 items selected from the KnowPain-12 validated instrument 4;

• Knowledge: 8 items adapted from the KnowPain-12 4;

• Satisfaction: an 11-item validated questionnaire from UNM, administered only Post-ECHO.

6. Discussion

• Participation in ECHO significantly improved healthcare provider’s self-efficacy and knowledge regarding chronic pain management and opioid use.

• No significant differences in attitude and behaviours were observed pre- and post-ECHO, nor were there any observed differences between professions, case presenters, or number of sessions attended.

• No significant differences in knowledge change were observed between professions suggesting that ECHO was successful in enhancing provider knowledge about pain management equally for all ECHO participants.

• Satisfaction was high among HCPs attending ECHO, and significantly higher among those who present cases and those who attend more sessions.

• Only some selected items of a valid questionnaire were used, which may have affected showing a significant change in attitudes and behaviours.

7. Conclusion

• The ECHO model demonstrates an effective strategy to build capacity and increase access to CP management and safe opioid prescribing in the province of Ontario.

• This project may be used as a template for creating educational programs on other medical topics

5. Results

5.1 Descriptive Characteristics

• From June 2014 until March 2017, ECHO provided 124 weekly sessions.

• A total of 264 HCPs who attended ECHO were invited to complete the online questionnaire.

• Of these, 170 (64%) completed the Pre-ECHO questionnaire and 119 (45%) completed both pre- and post questionnaires.

Participants’ Characteristics

5.2 Self-efficacy

• A total of 109 participants completed this section.

• Self-efficacy improved significantly for all professions pre and post ECHO.

• The improvement in self-efficacy was significantly greater among Physicians/PA/NP than among the other professions (Pharmacists/RN or Allied Health Professionals) (p=.003).

• No significant differences were observed between participants who presented a case at ECHO compared to those who did not (p=.667).

• No significant relationship was observed between self-efficacy change and the number of ECHO sessions attended (p=.066).

8. References [1] Boulanger A, Clark AJ, Squire P, et al. Chronic pain in Canada: have we improved our management of chronic noncancer pain? Pain Res Manag. 2007;12(1):39-47.

[2] Arora S, Thornton K, Murata G, et al. Outcomes of treatment for Hepatitis C Virus infection by primary care providers. N Engl J Med. 2011;364(23):2199-2207.

[3] Dubin RE, Flannery J, Taenzer P, et al. ECHO Ontario Chronic Pain & Opioid Stewardship: Providing access and building capacity for primary care providers in underserviced, rural, and remote communities. Stud Health Tech Informatics. 2015;209:15-22.

[4] Gordon DB, Loeser JD, Tauben D, et al. Development of the KnowPain-12 Pain Management Knowledge Survey. Clin J Pain. 2014;30(6):521-527.

Contact information: echo.ontario@uhn.ca

Twitter: @EchoOntario, Facebook: EchoOntario

www.echoontario.ca

Fig. 1 The ECHO “Hub and Spoke” Knowledge Translation model

5.3. Attitudes and Behaviours

• A total of 110 participants completed this section.

• No significant differences were found with regards to attitudes and behaviours for the total sample and for each profession.

• No significant differences in attitude change were observed between professions (p=.276).

• No significant differences were observed between participants who presented a case at ECHO compared to those who did not (p=.559).

• No significant relationship was observed between attitude and behaviour change with the number of sessions attended (p=.826).

5.4. Knowledge

• 105 participants completed this section.

• Knowledge significantly increased from pre-test to post-test for all ECHO participants and for each profession category.

• No significant differences in knowledge change were observed between professions (p=.108)

• No significant differences were observed between participants who presented a case at ECHO compared to those who did not ((p=.546).

• No significant relationship was observed between knowledge change and number of ECHO session attended (p=.407).

Characteristics n = 119

Results

Profession n(%) Physician, Physical Assistant (PA), Nurse Practitioner (NP) Pharmacists , Registered Nurses (RN) Allied Health Professionals (Psychology, Physical Therapy,

Occupational Therapy, Chiropractor, Social Worker)

70 (59%) 22 (18%) 27 (23%)

Number of sessions attended Mean (SD) 15 (9.19)

Case presenter n (%) Yes No

69 (58%) 50 (42%)

3.6 4

3.6

2.6

4.5

5.1

4.2

3.1

1

2

3

4

5

6

7

Total(n=109)

Physicians/PA/NP(n = 63)

Pharmacists/RN(n = 21)

Allied HealthProfessions

(n = 25)

Tota

l me

an s

core

s

Self-efficacy Pre-post Mean Changes

Pre-ECHO

Post-ECHO

(p<.000) (p<.000)

(p<.000)

(p<.000)

2.5 2.6 2.6

2

2.5 2.6 2.6

2.1

0

0.5

1

1.5

2

2.5

3

Total(n=110)

Physicians/PA/NP(n = 64)

Pharmacists/RN(n = 21)

Allied HealthProfessions

(n = 25)

Tota

l me

an s

core

s

Attitudes & Behaviours Pre-post Mean Changes

Pre-ECHO

Post-ECHO

(p=.441) (p=.570)

10.1 10.7

8.9 9.5

12.7 13.6

12 10.9

0

2

4

6

8

10

12

14

16

Total(n=105)

Physician/PA/NP(n=62)

Pharmacist/RN(n=19)

Allied HealthProfessions

(n=24)

Tota

l Me

an S

core

s

Knowledge Pre-post Mean Changes

Pre-ECHO

Post-ECHO

(p=.000)

(p=.000)

(p=.002) (p=.028)

(p=.479)

(p=.240)

5.5 Satisfaction

• 117 participants completed this section

• Average of 96% of participants either strongly agreed or agreed with all the 11 satisfaction statements.

• No differences in satisfaction were observed between professions (p=.130 to .888) .

• Participants who presented a case were more likely to strongly agree with eight of the 11 satisfaction items compared to participants who did not present a case (p =.000 to .041).

• A significant positive relationships were observed between number of ECHO sessions attended and 5 of 11 satisfaction items (p= .000-.04)

4. Statistical Analysis

• Paired t-tests and Wilcoxon signed-rank tests were used to assess differences between pre- and post-ECHO.

• Change scores for each outcome were computed and differences between profession type and case presentation were evaluated using ANOVA, independent samples t-test or Mann-Whitney U test.

• Pearson’s or Spearman’s correlations examined the relationship between changes in outcomes and the number of ECHO sessions attended.