Evaluation of text messaging service on management of post-operative pain in opioid-naïve surgical patients

A prospective randomised two-arm study of opioid-naïve surgical patients consented and enrolled to the Nellie persona-based text message post-operative self-management service by the clinical pharmacy team compared to a control cohort. This study will take place in the surgical units of an Australian Major Hospital (Frankston hospital Surgical Short Stay Unit, Acute Medical and Surgical Unit and 5GN) with real-time follow-up and monitoring at home for 30 days post-discharge via SMS . We will compare the ‘Nellie intervention’, a persona-based, interactive and automated text messaging service with a ‘Nellie control’ arm, randomized in a 1:1 ratio. Nellie Intervention population will be invited to accept self-management smart messaging service with timed protocol text reminders on medication management, education on pain and reminders to return unused opioid medication. Education resource links are form betterhealth available at https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pain-and-pain-management-adults Real time data is collected on the Nellie dashboard once patients participate in the messaging. If a patient request further support or information they will be directed to their GP. There is no direct patient contact follow-up with phone calls beyond standard care. Message schedule for intervention group Day 0 Welcome message, "Hi, I'm Nellie, your self-care service. I wish to confirm if you want to join in. Get started by replying "accept". Don't reply if you didn't ask to join in." Evening message triggered by patient replying with 'accept" "Hi, it's Nellie. Thanks for joining. I'm here to help you manage your own health better. At times I'll send advice for you to act on. You can opt out at any time by replying STOP." Day 1 to 7, 14,21 and 30 "HowRu? Survey" references (1-6). Day 1 to 4 at 10:30 and 18:00 information to limit opioid use examples include: "Hi, Okay, keep taking your anti-inflammatory (if prescribed) along with regular paracetamol for now. Only use the Oxycodone, Tramadol or Tapentadol if required for severe pain not managed by your simple pain relief. The aim of pain relief medicine is to give you more function – you may not become 100% pain free. For more tips to help with your pain, you can text the word PAIN at any time, Nell" "Hi again, please avoid taking your pain medication at a dose higher than prescribed, as you may get more side effects like dizziness, drowsiness or constipation. Take care, Nell." "Remember, your body will continue to recover & the need for pain medication will gradually decrease. If you need some ideas about how to help with your pain, you can text the word Pain at any time. Take it easy, Nellie" "Hi, it's important that you know that you don't need to complete all of the pain medication you've been given. Only take it while you need it, Nell." "Hey, when you feel that your pain is controlled, stop your anti-inflammatory (if prescribed) & take paracetamol as required." "Hi there, it's really important that you only use your pain medication to relieve pain. There's a high risk of them causing you harm if you take it for other reasons, Nell." "Morning! If you're still in pain after you've finished your supplied medications, see your GP for advice. You can get some ideas about how to manage pain by replying to this message with the word PAIN, Nell." Pain extra information message optionally triggered by the patient replying with the word "pain". "Physical therapies can help to relieve pain. Gentle walking, stretching, strength or aerobic exercises may help to relieve pain. They can also help you stay mobile and improve your mood. Start slowly at first and gradually build up over a few days." "Relaxation is known to help with pain. Examples are meditation and yoga. Try it now, sit or lie down in a quiet spot and focus on breathing in and out deeply for at least a minute. How does that feel? Other ways to do this are to listen to relaxing music, read a book or watch something good on TV. For more information about how to manage pain, go to betterhealthpain" Day 7, 14, 21 and 30 Check-in message for reducing opioid use at 14:00 "Hi, strong opioids are not normally needed for more than a week. It's important to reduce your use as soon as your pain improves. Are you still taking Oxycodone, Tapentadol or Tramadol for your pain? Reply for Y or N (if you haven't)" If patient replies Y "Okay, there is a risk of addiction developing to opioids like Oxycodone, Tapentadol or Tramadol especially if taken for more than a few days. It's important to be careful & to switch to other ways of managing your pain as soon as you can. For more information about how to manage your pain see betterhealthpain" If patient replies N "Okay thanks. If you have any leftover Oxycodone, Tapentadol or Tramadol it is wise to return them to your local pharmacy for safe disposal. Your medication should not be shared with anyone. This may result in serious harm, Nell." Day 7 Advice to return unused medicines "If you have any leftover Oxycodone, Tapentadol or Tramadol it is wise to return them to your local pharmacy for safe disposal. Your medication should not be shared with anyone. This may result in serious harm, Nell." Day 30 at 15:00 "Hi, did you return any leftover Oxycodone, Tapentadol or Tramadol tablets to the local pharmacy? Reply Y (if you did) or No (if you didn't), or ALL USED (if you had none left to return)." NetPromoter satisfaction survey "Thanks for participating. The messages from me will now end. Remember, you can speak to your GP if you are concerned - they are there to help. Take care, Nellie." All patients (control and intervention) will receive standard clinical care and discharge medication counselling by the Pharmacy Team. Both populations will be invited to text responses to patient outcome questions according to the timed protocol via mobile text messages relating to pain, opioid use, satisfaction with Nellie and disposal of unused opioid medications via R-outcomes on the Nellie platform. R-outcomes is a family of short generic patient-reported outcome and experience measures (PROMs and PREMs respectively). PROMs are about the subject of care; PREMs are about the service provided. The Nellie platform is a web-based dashboard for clinicians to access and manage their patients, as well as being able to be tailored at the individual patient level. Message protocols are carefully designed to promote Nellie’s supportive persona, while delivering evidence-based key messages. The interactive nature of Nellie’s programs require patients to respond to Nellie’s requests for information and reply with algorithm-generated and appropriate responses. Evidence from evaluations of the UK version of the Nellie platform (which is called “Florence”) indicate that the use of smart messaging is more effective in influencing patient behaviour than standard informational text messaging alone. References 1. Benson T. Measure what we want: a taxonomy of short generic person-reported outcome and experience measures (PROMs and PREMs). BMJ Open Quality 2020;9:e000789. doi:10.1136/ bmjoq-2019-000789 2. Benson T, Sladen J, Liles A, et al. Personal Wellbeing Score (PWS)—a short version of ONS4: development and validation in social prescribing BMJ Open Quality 2019;8:e000394. doi: 10.1136/bmjoq-2018-000394 available at https://bmjopenquality.bmj.com/content/8/2/e000394 3. Edwards KJ, Walker K, Duff J. Instruments to measure the inpatient hospital experience: A literature review. Patient Experience Journal. 2015; 2(2):77-85. doi: 10.35680/2372-0247.1088. 4. Simple telehealth Florence, Nellie, Annie available at http://www.simple.uk.net/ 5. Patient reported outcome measures (PROMs) available at https://r-outcomes.com/ 6. Outcome report tools and resources available at https://www.semphn.org.au/resources/qi.html 7. Cottrell E, Cox T, O’Connell P, et al. Patient and professional user experiences of simple telehealth for hypertension, medication reminders and smoking cessation: a service evaluation. BMJ Open 2015;5:e007270.doi:10.1136/bmjopen-2014-007270 8. Cottrell E, McMillan K, Chambers R. A cross-sectional survey and service evaluation of simple telehealth in primary care: what do patients think?. BMJ Open. 2012;2:e001392. Doi:10.1136/bmjopen-2021-001392