An Evaluation of the Effectiveness of the Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis

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Abstract

Background

Electronic health (eHealth) is the use of information and communication technology in the context of health care and health research. Recently, there has been a rise in the number of eHealth modalities and the frequency with which they are used to deliver technology-assisted self-management interventions for people living with chronic pain. However, there has been little or no research directly comparing these eHealth modalities.

Objective

The aim of this systematic review with a network meta-analysis (NMA) is to compare the effectiveness of eHealth modalities in the context of chronic pain.

Methods

Randomized controlled trials (N>20 per arm) that investigated interventions for adults with chronic pain, delivered via an eHealth modality, were included. Included studies were categorized into their primary node of delivery.

Data were extracted on the primary outcome, pain interference, and secondary outcomes, pain severity, psychological distress, and health-related quality of life. Pairwise meta-analyses were undertaken where possible, and an NMA was conducted to generate indirect comparisons and rankings of modalities for reducing pain interference.

Results

The search returned 18,470 studies with 18,349 being excluded (duplicates=2310; title and abstract=16,039). Of the remaining papers, 30 studies with 5394 randomized participants were included in the review. Rankings tentatively indicated that modern eHealth modalities are the most effective, with a 43% chance that mobile apps delivered the most effective interventions, followed by a 34% chance that interventions delivered via virtual reality were the most effective.

Conclusions

This systematic review with an NMA generated comparisons between eHealth modalities previously not compared to determine which delivered the most effective interventions for the reduction of pain interference in chronic pain patients. There are limitations with this review, in particular, the underrepresented nature of some eHealth modalities included in the analysis. However, in the event that the review is regularly updated, a clear ranking of eHealth modalities for the reduction of pain interference will emerge.

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Evidence Synthesis for Decision Making 4

Sofia Dias, Nicky Welton, Alex J Sutton … (2013)

Inconsistency can be thought of as a conflict between “direct” evidence on a comparison between treatments B and C and “indirect” evidence gained from AC and AB trials. Like heterogeneity, inconsistency is caused by effect modifiers and specifically by an imbalance in the distribution of effect modifiers in the direct and indirect evidence. Defining inconsistency as a property of loops of evidence, the relation between inconsistency and heterogeneity and the difficulties created by multiarm trials are described. We set out an approach to assessing consistency in 3-treatment triangular networks and in larger circuit structures, its extension to certain special structures in which independent tests for inconsistencies can be created, and describe methods suitable for more complex networks. Sample WinBUGS code is given in an appendix. Steps that can be taken to minimize the risk of drawing incorrect conclusions from indirect comparisons and network meta-analysis are the same steps that will minimize heterogeneity in pairwise meta-analysis. Empirical indicators that can provide reassurance and the question of how to respond to inconsistency are also discussed.

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To provide recommendations for the core outcome domains that should be considered by investigators conducting clinical trials of the efficacy and effectiveness of treatments for chronic pain. Development of a core set of outcome domains would facilitate comparison and pooling of data, encourage more complete reporting of outcomes, simplify the preparation and review of research proposals and manuscripts, and allow clinicians to make informed decisions regarding the risks and benefits of treatment. Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 27 specialists from academia, governmental agencies, and the pharmaceutical industry participated in a consensus meeting and identified core outcome domains that should be considered in clinical trials of treatments for chronic pain. There was a consensus that chronic pain clinical trials should assess outcomes representing six core domains: (1) pain, (2) physical functioning, (3) emotional functioning, (4) participant ratings of improvement and satisfaction with treatment, (5) symptoms and adverse events, (6) participant disposition (e.g. adherence to the treatment regimen and reasons for premature withdrawal from the trial). Although consideration should be given to the assessment of each of these domains, there may be exceptions to the general recommendation to include all of these domains in chronic pain trials. When this occurs, the rationale for not including domains should be provided. It is not the intention of these recommendations that assessment of the core domains should be considered a requirement for approval of product applications by regulatory agencies or that a treatment must demonstrate statistically significant effects for all of the relevant core domains to establish evidence of its efficacy.

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Indirect treatment comparison/network meta-analysis study questionnaire to assess relevance and credibility to inform health care decision making: an ISPOR-AMCP-NPC Good Practice Task Force report.

Jeroen P Jansen, Thomas A Trikalinos, Joseph C Cappelleri … (2014)

Despite the great realized or potential value of network meta-analysis of randomized controlled trial evidence to inform health care decision making, many decision makers might not be familiar with these techniques. The Task Force developed a consensus-based 26-item questionnaire to help decision makers assess the relevance and credibility of indirect treatment comparisons and network meta-analysis to help inform health care decision making. The relevance domain of the questionnaire (4 questions) calls for assessments about the applicability of network meta-analysis results to the setting of interest to the decision maker. The remaining 22 questions belong to an overall credibility domain and pertain to assessments about whether the network meta-analysis results provide a valid answer to the question they are designed to answer by examining 1) the used evidence base, 2) analysis methods, 3) reporting quality and transparency, 4) interpretation of findings, and 5) conflicts of interest. The questionnaire aims to help readers of network meta-analysis opine about their confidence in the credibility and applicability of the results of a network meta-analysis, and help make decision makers aware of the subtleties involved in the analysis of networks of randomized trial evidence. It is anticipated that user feedback will permit periodic evaluation and modification of the questionnaire. Copyright © 2014 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

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Author and article information

Contributors

Brian W Slattery:

School of Nursing and Human SciencesDublin City UniversityGlasnevinDublin, 9Ireland353 017008034brian.slattery@dcu.ie

ORCID: http://orcid.org/0000-0001-8342-5781

Journal

Journal ID (nlm-ta): J Med Internet Res

Journal ID (iso-abbrev): J. Med. Internet Res

Journal ID (publisher-id): JMIR

Title: Journal of Medical Internet Research

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Print): 1439-4456

ISSN (Electronic): 1438-8871

Publication date Collection: July 2019

Publication date (Electronic): 17 July 2019

Volume: 21

Issue: 7

Electronic Location Identifier: e11086

Affiliations

[1 ] School of Nursing and Human Sciences Dublin City University Dublin Ireland

[2 ] Centre for Pain Research School of Psychology National University of Ireland Galway Ireland

Author notes

Corresponding Author: Brian W Slattery brian.slattery@ 123456dcu.ie

Author information

Brian W Slattery http://orcid.org/0000-0001-8342-5781

Stephanie Haugh http://orcid.org/0000-0002-6731-1298

Laura O'Connor http://orcid.org/0000-0001-5636-803X

Kady Francis http://orcid.org/0000-0001-8161-4546

Christopher P Dwyer http://orcid.org/0000-0001-5935-4338

Siobhán O'Higgins http://orcid.org/0000-0001-8793-8795

Jonathan Egan http://orcid.org/0000-0002-7205-0862

Brian E McGuire http://orcid.org/0000-0002-3540-6639

Article

Publisher ID: v21i7e11086

DOI: 10.2196/11086

PMC ID: 6668295

PubMed ID: 31317869

SO-VID: 84408efa-3057-4ad1-8624-30f626b6a46f

Copyright © ©Brian W Slattery, Stephanie Haugh, Laura O'Connor, Kady Francis, Christopher P Dwyer, Siobhán O'Higgins, Jonathan Egan, Brian E McGuire. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 17.07.2019.

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/.as well as this copyright and license information must be included.

History

Date received : 18 May 2018

Date revision requested : 30 August 2018

Date revision received : 20 December 2018

Date accepted : 6 January 2019

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