Delivery Model Matters for Digital Interventions in Pain Self-Management: Mixed Methods Study

Clinical Snapshot

Key Findings

• P Value: Reported as statistically significant for secondary outcomes; not significant for primary outcome (pain interference) in EPIONoFollowUp vs control comparison; specific p-values not provided in abstract

• Effect Size: Not reported in abstract; effect sizes for between-group differences on secondary outcomes not quantified

• Primary Outcome: Pain interference (BPI): statistically significant between-group differences were NOT demonstrated for EPIONoFollowUp vs care-as-usual controls on the primary outcome. Significant differences were found for secondary outcomes: HRQoL, pain acceptance, and pain catastrophizing (favouring EPIONoFollowUp over controls); self-regulatory fatigue (favouring EPIOBlendedCare over EPIONoFollowUp)

• Nnt Or Sensitivity: NNT not calculable from available data. Program engagement: EPIONoFollowUp median 10 days of use (IQR 3–24) vs EPIOBlendedCare median 30 days (IQR 13–44); module completion ≥7/9: 23% (17/73) EPIONoFollowUp vs 62% (78/125) EPIOBlendedCare

• Confidence Interval: Not reported in abstract

Clinical Application

Digital self-management programs such as EPIO are feasible to implement at scale with low marginal cost per user. The blended-care model requires modest clinician time for follow-up support but substantially improves engagement and module completion. The finding that unguided digital delivery yields lower engagement (10 vs 30 median days; 23% vs 62% module completion) has direct implications for implementation planning. Clinicians and health services should anticipate that simply providing access to a digital program without structured follow-up will result in suboptimal engagement for many patients. Australia's chronic pain burden is substantial, with approximately 3.4 million Australians living with chronic pain (AIHW data). Access to multidisciplinary pain management services remains inequitable, particularly in rural and remote areas, making digital self-management programs highly relevant. The RACGP supports self-management approaches for chronic pain within a biopsychosocial framework. While EPIO is not currently available on the Australian market or PBS-subsidised, analogous programs exist (e.g., THIS WAY UP, Pain Course by the University of Sydney). The TGA regulates digital health tools as Software as a Medical Device (SaMD) under the Therapeutic Goods Act 1989. The study's finding that blended-care delivery is superior to unguided access is directly relevant to Australian telehealth models, particularly post-COVID-19 MBS telehealth item expansion. For Australian primary care, integrating brief nurse or allied health follow-up with digital pain programs — consistent with the blended-care model — would likely optimise outcomes. The education-level moderation finding is particularly relevant to health equity considerations in Australian Indigenous and low-socioeconomic communities. Adults with chronic pain of varied aetiology who are candidates for digital self-management programs, particularly those with moderate digital literacy. Most applicable to community-dwelling adults aged 30–60 years. Findings are most directly applicable to patients similar to the study sample: predominantly female, educated, Norwegian adults. Caution is warranted in applying findings to males, older adults, those with low digital literacy, or those with severe or complex pain presentations.

Abstract

BACKGROUND: Digital health interventions can improve access to and outreach of evidence-based support for people living with chronic pain. How best to deliver such interventions remains unclear, however, and although guided or blended care models show promise, digital interventions are primarily delivered without support or follow-up. OBJECTIVE: This study aimed to compare the use and effect of the evidence-based digital pain self-management intervention EPIO when (1) delivered through digital download without follow-up (ie, EPIONoFollowUp), compared with (2) delivery through a simple blended-care model (ie, EPIOBlendedCare), or care-as-usual controls. METHODS: People (n=73) with chronic pain received access to the EPIO program through individual download (EPIONoFollowUp). Program use and outcome measures were collected over 12 months and compared with findings from a separate randomized controlled trial in which people with chronic pain (n=266) were assigned to receive EPIO through a simple blended care model (EPIOBlendedCare) or to a care-as-usual control group. Outcome measures were collected at baseline and at 3, 6, and 12 months and included pain interference (Brief Pain Inventory [BPI]; primary outcome), pain severity (BPI), anxiety and depression (Hospital Anxiety and Depression Scale), self-regulatory fatigue (Self-Regulatory Fatigue Scale-18), health-related quality of life (HRQoL; RAND 36-Item Health Survey), pain catastrophizing (Pain Catastrophizing Scale), and pain acceptance (Chronic Pain Acceptance Questionnaire-8). Generalized linear models for repeated measures were fitted to explore between-group differences over time. Interviews with the EPIONoFollowUp group (n=15) exploring perceived program experiences were analyzed using rapid analysis. RESULTS: Participants (N=332) had a median age of 49 (IQR 39-55) years, were primarily women (271/332, 82%), and had a variety of pain conditions. Statistically significant between-group differences in favor of the EPIONoFollowUp group compared with the control group included improved HRQoL and pain acceptance and reduced pain catastrophizing. Intervention group comparison revealed only 1 significant between-group difference, for self-regulation, in favor of EPIOBlendedCare. Participants receiving the EPIONoFollowUp delivery model displayed lower program use, averaging 10 (IQR 3-24) days of use vs 30 (IQR 13-44) days for EPIOBlendedCare. Similarly, 23% (17/73) of the EPIONoFollowUp group participants completed ≥7 of 9 modules, compared with 62% (78/125) in EPIOBlendedCare. Higher education level was associated with significant improvements in pain severity, anxiety, HRQoL, and pain catastrophizing, as well as higher module completion, in the EPIONoFollowUp group but not in the EPIOBlendedCare group. Qualitative findings identified a preference for more follow-up, as well as positive changes in awareness, acceptance, and coping in the EPIONoFollowUp group. CONCLUSIONS: The delivery model should be considered when providing access to digital self-management, and models with guidance appear to be the most helpful. When health care resources are limited, blended care delivery should likely be chosen for those who need it most, for example, those with lower education.