Background
Methods
Participants
Interviews
Data analysis
Results
Characteristic | N (%) or Median (range) |
---|---|
Age (years) | 63 (30–78) |
Gender | |
Men | 9 (30%) |
Women | 21 (70%) |
Race | |
Asian | 2 (7%) |
Black / African American | 10 (33%) |
White / Caucasian | 18 (60%) |
Ethnicity | |
Hispanic | 1 (3%) |
Not Hispanic | 29 (97%) |
Healthcare coverage | |
Private health insurance | 9 (30%) |
Medicare / Medicare advantage | 15 (50%) |
Medicaid / Medicaid replacement | 7 (23%) |
Smartphone use | |
Independent to download and learn new apps | 17 (57%) |
Needs assistance downloading and learning new apps | 6 (20%) |
Smartphone user but not for apps | 5 (17%) |
Not a smartphone user | 2 (7%) |
Psychiatric history, reported in medical record | |
Depression | 9 (30%) |
Anxiety | 7 (23%) |
PROMIS scores | |
Depression | 52.4 (34.2–69.5) |
Anxiety | 59.5 (38.3–73.3) |
Characteristic | N (%) |
---|---|
Clinical role | |
Orthopedic surgeon | 13 (59%) |
Non-operative physician | 3 (14%) |
Nurse practitioner | 2 (9%) |
Nurse | 2 (9%) |
Medical assistant | 2 (9%) |
Physician rank | |
Assistant professor | 8 (36%) |
Associate professor | 5 (23%) |
Professor | 3 (14%) |
Gender | |
Men | 11 (50%) |
Women | 11 (50%) |
Race | |
White / Caucasian | 16 (73%) |
Black / African American | 1 (5%) |
Asian | 2 (9%) |
Multi-racial | 1 (5%) |
Other | 1 (5%) |
Ethnicity | |
Hispanic | 1 (5%) |
Not Hispanic | 21 (95%) |
Digital mental health intervention
Theme | Representative quotes |
---|---|
Feasibility
| |
Appealing: The ease of referring a patient to an app is appealing to orthopedic clinicians and clinical support staff, especially if the added resource reduces how much the patient needs to navigate mental health and pain challenges through the orthopedic office. Ideally, the app could be somewhat customized to the orthopedic patient population, even to the relevant body part or surgery (e.g., post-operative precautions, activity progression). | “I think an app like this would be amazing for a huge portion of the patients that we have.” (Medical assistant) “I’m not saying to a patient, ‘I’m treating your depression with this.’ I’m telling the patient, ‘This is a resource that we have, that we use as an option to help improve the patient’s well-being.’” (Physician) “This, to me, would not be very difficult to discuss and just provide the information. Like, ‘Here’s an app. This is a platform you can use, and we highly recommend it. By no means do you have to use it.’ I mean, it’s a conversation piece. It’s not like we’ve got to spend 30 minutes discussing this…And quite honestly, we spend a lot of time talking to patients about their pain and about how it’s affecting their lifestyle. And it may even take some of that off of us because now they’re using their app versus us.” (Nurse) |
Persistent implementation concerns: Potential barriers to delivering a mental health app in the orthopedic care setting include: (1) out-of-pocket costs for patients, and (2) the concern for added medicolegal liabilities and responsibilities out of the scope of practice for orthopedic clinicians and team members. | “I’m on a fixed income, so any increase in my healthcare cost, I’ve got to monitor pretty closely. I’ve seen people on social security who budget – they don’t have an extra $5 to spare.” (Patient, 44-year-old White man) “[Maybe] you can get it from your health insurance, and they pay for it.” (Patient, 40-year-old White woman) “My first thought is that this would probably be a nice resource for patients. My second thought is, if you initiate some intervention or application, what kind of legal responsibility do you have based on that output? What I don’t want to do, personally, is increase my medicolegal risk on being responsible for intervening or providing outputs to patients where I have no knowledge base or expertise.” (Physician) |
Acceptability
| |
Digital advantages: The app was appealing to orthopedic patients who: (1) were interested in self-help resources, (2) did not feel ready or interested in reaching out to a person for mental health assistance, and (3) wanted convenient access to on-demand resources. | “I think this is excellent because people have access and the ability to look it up and say, ‘Oh, I’m getting stressed out about this. What exercises do I do?’” (Patient, 71-year-old Asian man) “I believe with the app, it’s a safety for those that choose not to get out to see someone face-to-face. Because even me going to counseling, I didn’t want the stigma of having to go to therapy… I had a family member that just said that she wouldn’t mind doing therapy if she can do it through text. And I was like, ‘How deep is that?’ Because a lot of things, sometimes people can’t verbalize or vocalize what it is they’re feeling, but they can write it down to you.” (Patient, 31-year-old Black woman) “Online resources are sometimes the only thing that patients have. I was in a wheelchair for months, and I just couldn’t go places. I was in so much pain. You go by what you can find online.” (Patient, 43-year-old White woman) “I love that they have times available that are really late. Because sometimes with my schedule, by the time I can actually sit down and focus on something, it’s 10:00 PM.” (Patient, 40-year-old White woman) “I think the app will be very helpful to have when it’s late or when it’s early morning and you’re not getting any sleep or something.” (Patient, 60-year-old White man) “For it to be here waiting for me, not having to try to navigate getting into a shrink and all of that nonsense with my primary – just any chance to introduce more mental healthcare, I think is good, honestly.” (Patient, 44-year-old White man) |
Tech savviness dependent: Orthopedic patients, clinicians, and clinical support staff agreed that digital interventions such as smartphone apps are preferred by many patients. They tend to be more preferred by young and middle-aged adults and less appealing to patients who are not “tech savvy,” including many (but not all) older adults. Estimates for the proportion of clinicians’ patient populations who might be interested in a digital intervention ranged from 5–70% and clustered around 20–25%. | “[Patients] are on their phones a lot more. Everything’s going to their phones. Even when they’re in pain or if they’re miserable or something, their phones are a lot more accessible than a laptop or a piece of paper. I give them a whole packet and they’ll say, ‘I know you gave me some stuff and I wrote it down somewhere, but I don’t know where I put it.’” (Medical assistant) “We have an online database for a particular surgery that we do, and I think 30% of my patients request paper surveys. Which is insanely high. For every other person in my division, it’s like 5–15%. So, it just tends to be my geographic location, I think, because it’s a lot of people from rural areas. They maybe don’t really like using their smartphone, so it’s a challenge. I think it’s going to be less of a challenge, and there are more and more elderly people that are used to these things, but that’s going to be your toughest population to hit with any kind of digital intervention – the elderly.” (Physician) “I would give it a shot because, like I say, we’re getting older, and we need to know how to mentally deal with our aches and pains. We really do.” (Patient, 70-year-old Black man) “I don’t know that I would use my phone that way.” (Patient, 67-year-old white woman) |
Patient situation dependent: Patients expressed particular interest in a mental health app that addressed their coexisting orthopedic pain and limitations. Patients anticipated using a mental health app more frequently if they found it to be helpful, if they were having a flare of pain or depressed or anxious thoughts, and if the app’s interventions were short and succinct. Some, but not all, of patients also appreciated reminder notifications within the app, and some, but not all, desired their input into the app to be linked back to their medical record. | “I can think of so many people I know with chronic pain that would love this app, actually.” (Patient, 47-year-old Black woman) “Ultimately, it’ll be whether I continue to see results from it. But right now, I’m actually pretty excited. I’ve been waiting for something like this to link my mental health with the pain that I’m in. So yeah, I’m gung ho.” (Patient, 44-year-old White man) “Notifications, to be honest. And then also when I’m just experiencing pain, that’s when I think I would use it more.” (Patient, 64-year-old White woman) |
Evidence dependent: Before recommending a mental health app to patients, orthopedic clinicians want details on the content and delivery of the actual intervention, and they want to be reassured of the quality of the intervention and how patients will perceive it. There is some concern regarding reliance on a chatbot to deliver an intervention. | “The big question that I would have is, ‘How does this compare to seeing a ‘real person’?’’ But this is presumably going to be better than nothing.” (Physician) “I feel like people still want to talk to people. I think having a licensed provider on the other end to chat with them is better than a bot.” (Physician) |
Facilitators for implementation: Facilitators reported by orthopedic patients and clinicians for delivering a mental health app to orthopedic patients include: (1) a printed informational “Getting started” handout for patients, (2) centralized phone support to assist patients in onboarding to the app, and (3) clear liability policies and a support path which does not filter mental health related questions or crises to the orthopedic clinician. | “It’s not like [our staff] are going to go through it and help put the app on the patient’s phone and go through that. Anything extensive like that might be like, ‘Oh gosh, we don’t have time to set it all up and to actually get them going with it and that type of thing.’ So yeah, I think being able to have a printed ‘How-to’ thing – to give that to them would be, I think, helpful.” (Nurse practitioner) As an older person, I learn more through visuals. I’m finding that if I hear and see it, I can retain it better. If somebody talks to me and tells me how to get through the app, then that would be better for me. The verbal, as well as the instructional handout, would be great.” (Patient, 71-year-old Black woman) “I’m assuming there’s a back-end to this app with someone monitoring it…We’re treating the patient and they’re putting information out there that we’re not receiving or monitoring. And what happens if this app captures a problem?” (Physician) |
Usability
| |
Varied proficiency: Although not universally true, some older and even middle-aged orthopedic patients expressed interest in using the app but had more difficulty than they anticipated navigating through the app. In contrast, some patients had no difficulty at all navigating to tools within the app, although these patients tended to be younger. | “It seemed pretty self-explanatory….Nothing was confusing.” When asked to schedule a session with the human coach: “I wouldn’t know how to get to that… I’m not sure how I got here, but I guess I just keep going back.” (Patient, 78-year-old White woman) “It’s actually pretty clear, pretty cut and dry, which is good.” (Patient, 47-year-old Black woman) |
Password recall: The most common barrier to patients using the app was that many iOS (Apple iPhone) users could not remember their App Store password and therefore could not immediately download the app, even though the download was free. | “I think they want me to enter…my Apple ID? I think I will have to go home and check it.” (Patient, 71-year-old Asian man) |
Printed mental health resource guide
Theme | Representative quotes |
---|---|
Feasibility
| |
Superior to a digital intervention: Orthopedic clinicians and clinical support staff expressed that delivery of a printed intervention would be even quicker and easier to integrate into current workflows than delivery of a digital intervention. | “This would be, to me, like handing out a piece of paper on icing instructions. You can provide the resource for them to get more information, but this is more of a passive approach where patients, if they need it, can look at it. I think this would be more reasonable [than an app] because then I’m not providing their care. They’re able to go to this and say, ‘Hey, gosh, if I really want to do yoga training or whatever, I can go click on that.’ Or, ‘If I really truly need mental health resources and I don’t know how to get it, oh, that’s a nice resource.’ But it’s very passive. And I prefer that because then I don’t think any of that’s going to come back as me trying to provide care.” (Physician) “I think there are easier flows on this end [compared to an app]… My nurse could very easily print this out and hand this to the patient as she’s handing them all their other stuff for their appointment.” (Physician) |
Acceptability
| |
Sometimes preferred over a digital intervention: Orthopedic patients, clinicians, and clinical support staff agree that a printed resource option is more appealing than a digital intervention for some patients. The printed intervention was especially appealing to orthopedic patients who: (1) are not frequent mobile device users, (2) prefer “tangible” information, and (3) prefer local, in-person support for mental health matters. Estimates for the proportion of clinicians’ patient populations who might be interested in a printed intervention was similar to estimates for the digital intervention. | “Someone like me that is not used to just looking at their smartphone or their iPad for everything – they might prefer [this guide] to the app.” (Patient 78-year-old White woman) “Some people just like paper.” (Patient, 46-year-old White woman) “I like this a lot, because again, it’s local. It’s resources within our city, and it’s easy. I like this. Honestly, I would prefer this to [an app], if it was a one-or-the-other…I like the idea of an app, and once I start using it, I might change my mind. But I like that this [guide] lists resources within the state I live. It’s like, tangible places that are conceivably here.” (Patient, 40-year-old White woman) “I think the same number as the app. I think I would give this to the same patients that I would try to set up with the app.” (Physician) |
Engagement concerns: Potential patient-facing barriers to using a printed guide include: (1) affordability for the resources listed on the guide, and (2) the potential to lose the paper on which the guide is printed. | “For this [resource on the guide], you mention the fee is set on a sliding scale ranging $15 to $40. I think putting information about insurance and also the price has effect on our decision…So one decision rule is, what is the price, not just, which kind of service [the resource] is offering.” (Patient, 30-year-old Asian man) “If there is a space in MyChart where people can find resources, or even send an e-mail out – because I lose paper.” (Patient, 35-year-old Black woman) |
Facilitators for implementation: Orthopedic patients, clinicians, and clinical support staff suggested that a facilitator to delivering a printed intervention to patients could include making the handout available at multiple time points during the orthopedic encounter (e.g., in the waiting room, on the clinic’s public-facing website, as paperwork received at clinic discharge, and/or via patients’ online medical portal). It could be offered to all patients who screen positively for high symptoms of depression or anxiety, and/or it could be offered to patients who are identified by the clinical team to have symptoms of depression or anxiety that interfere with their orthopedic clinical care. Orthopedic patients largely prefer receiving the printed guide after their encounter with the clinician, as a response to their interaction with the clinical orthopedic team. | “You can leave something like this in the rooms and with flyers that they can post on the walls. And I mean, that’s something you put on the wall in the room that says, ‘Resources.’ If anybody wants to take a picture of it on their phones or go to the QR codes, they can.’ And that way they can also do it if they’re by themselves in the room.” (Physician) “For our patients in our [more complex] clinics, we have a packet that we give to patients, so having this incorporated in that would be really helpful.” (Physician) “I might not give it to the [straightforward] patient, but if they, on their own, are looking and find out that this is a resource for them – they may also have chronic pain [in another body part] that I’m unaware of or that wasn’t a focus of our visit – then they may avail themselves of this. So, I think having it for everybody, but not necessarily printing it out for everybody, is probably helpful.” (Physician) “I also think that maybe you should put it on the MyChart app. (Patient, 35-year-old Black woman) “I’d want to see this after I see the doctor…And it could come from the doctor or the nurse.” (Patient, 71-year-old Black woman) |
Facilitator for use: Many orthopedic patients would prefer for the orthopedic clinical team to select and briefly discuss a few resources from the printed guide which they are most encouraged to pursue. | “I think it’s a good option, but I believe they have to explain some of the stuff, at least in the guidance. So it’s not like, just give [patients] the guidance and they read it later. Maybe give them some idea about how everything works, make some motivation for the people to use it. If [patients] have some extra information other than having just the guide, I think if you discuss it, maybe they take it more seriously and do one of the steps.” (Patient, 30-year-old Asian man) “I think the provider would need to probably circle one or two things they want the person to do because I think if you just hand them this resource list, I feel like they’re not going to do anything, or they’re not really going to know what to do. I think if you have one thing you want them to do and point them to that, there’s a higher chance they’ll actually do it. But I think this is a great resource for providers, too – like a menu box of which ones we’re going to choose for this particular patient, something like that.” (Physician) |
Usability
| |
Format preferences: Orthopedic patients, clinicians, and clinical support staff preferred that a printed guide be no longer than two double-sided pages, with large font, simple language, bullet points, clear cost information, bold colors, and an intuitive, yet pleasing format. When delivered electronically, URLs should be active hyperlinks. When delivered on paper, QR codes can be included on the guide to facilitate access to resource URLs, but QR codes may overwhelm and deter some patients from further exploring the guide. | “I like that it’s narrowed down. Because I’ve looked for stuff like this before, and if you Google it, it’s overwhelming. Because you have so many options and it’s like, ‘How do I boil it down?’” (Patient, 40-year-old White woman) “This is paper. If this were electronic and these were clickable, I might find it more useful. I could click on [a resource], and I wouldn’t have to type it in.” (Patient, 70-year-old Hispanic woman) “I think this would be great. I think the only drawback I see with this would be our patients that are not tech savvy. I just learned how to use QR codes. I’m 40, so I don’t think… I don’t know that my 75-year-old mom could use the QR code. I don’t know. So I think that just making sure it’s all-around age friendly. Making sure it’s functional and easy for those patients who may not be tech savvy is going to be a big priority.” (Medical assistant) |
In-person mental health support
Theme | Representative quotes |
---|---|
Feasibility
| |
Skepticism: Many orthopedic clinicians questioned the financial and logistical feasibility of in-person support from a mental health specialist within the orthopedic clinical environment. | “I think [a counselor or social worker] would be very helpful, but I don’t see it happening in this day and age in healthcare.” (Physician) “I don’t think there are enough patients, at least in my practice, to make it work out.” (Physician) |
Acceptability
| |
Ideal for some patients: Orthopedic clinicians, clinical support staff, and patients expressed that a subset of patients require and prefer one-on-one in-person mental health support. | “I think in-person options are going to be the key. Handouts are great, but then they’re like, ‘Okay, now what? Are you going to schedule me with somebody? Is there somebody I can talk to? If you can’t help me, who’s going to help me? My primary care provider doesn’t want to deal with this. What do I do now? This isn’t a pain management doctor problem. So now what do I do?’” (Medical assistant) “For a lot of patients, I’ve told them that they need to see or try to find a psychiatrist, but they always have trouble finding one.” (Physician) “I think it would be awesome to have a therapist that will come in and speak to you for maybe five, ten minutes that can give pointers, things that you can do to help, say, if a person needs it.” (Patient, 35-year-old Black woman) “I like to see them face to face. I like to have the interaction where you can see my face. You could follow up with a phone call or a computer, but initially I would like to have a face, a Zoom call, or something so you could see the expression on my face.” (Patient, 71-year-old Black woman) |
Considerations for various care models: Orthopedic clinicians proposed various models to integrate in-person mental health support into the orthopedic care plan. Compared to orthopedic teams that care for relatively acute and correctable conditions, clinicians and support staff who predominantly care for patients with chronic conditions, spine conditions, and/or life-altering (e.g., major traumatic or oncologic) conditions more frequently expressed that a departmental social worker or counselor would be an important resource, as opposed to referral to an outside resource. | “There are a couple applications for social workers that I think would be helpful. One would be mental health counseling. The other is for patients that are uninsured or underinsured to give them resources and help with things. So, I think there’s utility for multiple roles that someone like a social worker can play, and I think that would be very beneficial. It can be one [social worker] at each clinical location. We’re not asking them to take on all of our patients. It’s a subset for sure.” (Physician) “Just a list of names of people that maybe we have a relationship with – a psychiatrist that maybe we can refer them to would be nice. Maybe forming some relationships with some psychiatrists. I think that, and then maybe some psychologists, as well.” (Physician) “I think it depends on the clinic. I mean, maybe in some ways you could consider having a ‘complex patient’ clinic and have more resources available there. Have longer appointment times, more resources available – like a psychologist or psychiatrist – at those visits.” (Physician) |
Research considerations
Theme | Representative quotes |
---|---|
Feasibility
| |
Clinical team interest and facilitators for recruitment success: Most orthopedic clinicians would be interested in contributing to a mental health related trial if participation is convenient such that: (1) the eligibility criteria are well-defined, (2) a dedicated research member is present real-time to complete the vast majority of the recruitment and enrollment activities, (3) frequent reminders are sent to clinicians as needed, (4) the study does not interfere with other ongoing studies, and (5) enrollment does not slow down clinic flow (e.g., due to space limitations). Study advertisements in the patient rooms would help patients initiate the conversation and would remind clinicians to discuss it, as well. | “The less work that we have to do in clinic to enroll somebody and the less it slows us down, the more likely I’m going to be to enroll patients. Then also make it very clear and easy to identify inclusion and exclusion criteria, because that’s always a difficult thing to remember in a busy clinic.” (Physician) “I think there has to be somebody to do it, whoever that is. There has to be a person for whom it’s on their radar. I feel like most of the time, my brain is full or empty or whatever. It usually can’t handle much more, you know?” (Physician) “If my team knows, I can ask them ahead of time to identify the patients. They can put a note in the appointment comment, or they can remind me as I’m running down the hallway to my next room. And then have something in the rooms, like a little a flyer in a brochure holder. Because then I have a visual reminder in the room when I’m engaging with the patient.” (Nurse practitioner) “I think it’s important to know that a lot of patients at [this institution] are enrolled in a lot of different studies. There’s a lot of concern when you introduce a new study that it’s going to impact the results of another study, which may be industry funded.” (Physician) |
Patient interest and facilitators for enrollment success: Orthopedic patients report that motivators to participate in a mental health related randomized controlled trial in an orthopedic care setting include: (1) a desire to improve their pain and function, and (2) a desire to help people. Many orthopedic clinicians believe patients would be more likely to participate in the research study if: (1) the clinician voices support for the study and recommends it, (2) the topic is introduced in an approachable and compelling manner, and (3) the added burden is minimal. | “For me, the interesting part of this is I feel like I’m suffering from mental issues, and at the same time, have the pain. So if there is really a relationship between these two and if there is a solution, I really would like to know. That’s the reason to participate for me.” (Patient, 30-year-old Black woman) “I think it’s important for somebody on the [clinical] team to mention the study to the patient. ‘Hey, we’re doing this study. We think it can be potentially really helpful. Would you mind talking to the research coordinator?’” (Physician) “I think just the presentation – having them feel accepted and that this is really looking at an overall perspective for health and wellness…that we’re on their side and they’re not feeling, I guess, judged or bad. Taking a more positive approach to it. I think that delivery would be helpful for them to accept it.” (Nurse practitioner) “If it were a lot of time or a lot of effort for anyone, they would not be okay with it.” (Physician) |
Patient barriers to participation: Patients reported the following anticipated barriers to participation: (1) worsening of mental health such that the patient loses motivation and energy to participate in typical daily activities, or (2) excessive burden from the study. | “One, if I can afford it, and two, if I can get there. And three, if my mental capacity is willing to take this on that day. But yeah, I definitely would [participate].” (Patient, 35-year-old Black woman) “If you catch me while I’m down and not feeling great about things, it would be harder to find the motivation to try something new, even if it would be helpful.” (Patient, 44-year-old White man) |
Acceptability
| |
Acceptability of randomization: Generally, orthopedic clinicians believe patients would be willing to participate and be randomized to one of a variety of mental health interventions. While most patients expressed willingness to be randomized, many also expressed a preference for one intervention over the other (e.g., digital or printed). Offering all interventions by the end of the study period increased the appeal to many patients. | “I think patients are less likely to participate and be randomized into interventions where they have a vested interest and a clear prejudice for a certain outcome…Trying to get somebody to commit to a randomization for surgery is very difficult because they may have strong feelings, but for this, I don’t think that they’re going to feel strongly about it.” (Physician) “To me, either one would be okay.” (Patient, 71-year-old Black woman) |