Speakers

Trevor Lentz, PT, PhD
Tyler Cope, PT, DPT, ACT
Duke Clinical Research Institute
Duke Department of Population Health Sciences
Durham Veterans Administration

Slides

Keywords

AIM-Back; Clinical site recruitment; Cluster randomized trial; Low back pain; Recruitment funnel

Key Points

• Low back pain is an impactful condition that is more common in the veteran population. Typical low back pain care involves imaging and pharmacologic treatments that don’t always resolve pain issues and may lead to more invasive injection-based or surgical measures that often don’t result in better outcomes.

• Research has shown that non-drug treatments (eg, cognitive behavioral therapy [CBT], yoga, physical therapy [PT]) are effective but not often used.

• The AIM-Back trial (Improving Veteran Access to Integrated Management of Back Pain), an embedded pragmatic cluster randomized trial, sought to restructure care practices in Veteran’s Administration (VA) healthcare systems to promote and facilitate 2 clinical non-drug pathways that are supported by established guidelines as first-line treatment for low back pain.

• Two care pathways were developed in coordination with VA clinicians, veterans, and care givers: (1) Sequenced Care Pathway – This pathway provided an initial onsite physical therapy evaluation and treatment session followed by weekly telehealth physical activity training for 6 weeks. The patient then saw the physical therapist again and was either discharged or provided with 6 weeks of training in psychologically-informed practices to help patients manage pain. (2) Pain Navigator Pathway – In this pathway, a local site clinician who was trained by the study team as a pain navigator discussed and facilitated alternative treatments for low back pain (eg, PT, yoga, CBT, massage). Patient follow up at both 6 and 12 weeks assessed progress and outcomes.

• AIM-Back used a novel and intentional recruitment method, borrowing the concept of the business sales funnel, to generate as many site leads as possible. The recruitment process was systematic involving a 3 step framework: (1) Identify leads, (2) Approach leads, (3) Engage and select sites.

• In step 1, leads were identified through Warm Market methods (sites known to the researchers), by Leveraging Data (evaluating lists of providers for potential fit), and through traditional Promotional Outreach efforts (advertising through networks and listservs). AIM-Back identified 184 leads from 53 VA healthcare systems.

• Step 2 involved approaching leads through email messages. AIM-Back learned that promoting the trial in a way that helps clinicians solve their problems instead of asking clinicians to help with the research was more likely to yield the site. AIM-Back received responses from 23 VA healthcare systems.

• In step 3, AIM-Back engaged personnel at all levels, from leadership to clinicians, to assess feasibility and buy-in at the site. AIM-Back selected 19 participant sites within 10 VA healthcare systems.

• The Promotional Outreach strategy proved most effective with 9 (47.4%) of sites resulting from this strategy. The Leveraging Data strategy netted 6 (31.6%) sites, and 4 (21.1%) sites came from the Warm Market strategy. Site recruitment took approximately 3.6-3.8 months on average.

• 17 sites enrolled 1817 Veterans with most sites (n=16) meeting or exceeding the minimum enrollment goal. When sites chose not to participate, they cited a reluctance to change their existing programs, a lack of clinicians or resources, or they were already participating in similar trials.

Discussion Themes

AIM-Back messaging evolved over the course of recruitment from a more traditional trial marketing email to an email that was more personal, short, and leveraged the standing of Duke University. This more personal approach to recruitment led to better relationships with sites during the trial.

Project management software can be helpful for tracking follow up with site leads and communication during the recruitment process.

One overall goal of AIM-Back was to set up a new clinical program that could continue after the end of the trial. Sites were given training materials for the centralized study components and support from AIM-Back was stepped down slowly. Sites that chose to continue the intervention trained a physical activity/whole health coach and a PT for the psychologically informed PT portion of the intervention.

Indicators of a potentially successful site included qualitative components that reflect a high level of engagement such as high interest and excitement in the study along with a sufficient patient population.

Read more about the AIM-Back trial design.